MEDICARE: HOLLIE STEWART DAVENPORT LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	7142	TN

General Provider Information

NPI Number	:	1619681202
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HOLLIE STEWART DAVENPORT LCSW

Provider Business Mailing Address
First Line	:	PO BOX 6000
Second Line	:
City	:	MOUNTAIN HOME
State	:	TN
Zip	:	37684-6000
Country	:	US
Telephone Number	:	423-926-1171
Fax Number	:	423-979-2645

Provider Business Practice Location Address
First Line	:	CORNER OF LAMONT & VETERANS WAY
Second Line	:	BUILDING 160
City	:	MOUNTAIN HOME
State	:	TN
Zip	:	37684-6000
Country	:	US
Telephone Number	:	423-926-1171
Fax Number	:	423-979-2645

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/09/2023
Last Update Date	:	01/09/2023

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