MEDICARE: DR. KIM DAVENPORT PSY.D.

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	103TC0700X	Clinical Psychologist	0810003696	VA

General Provider Information

NPI Number	:	1790925089
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KIM DAVENPORT PSY.D.

Provider Business Mailing Address
First Line	:	424 S WASHINGTON ST
Second Line	:	# 2A
City	:	ALEXANDRIA
State	:	VA
Zip	:	22314-4100
Country	:	US
Telephone Number	:	703-314-5756
Fax Number	:

Provider Business Practice Location Address
First Line	:	424 S WASHINGTON ST
Second Line	:	# 2A
City	:	ALEXANDRIA
State	:	VA
Zip	:	22314-4100
Country	:	US
Telephone Number	:	703-314-5756
Fax Number	:

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

Provider Enumeration Date	:	02/25/2009
Last Update Date	:	06/08/2014

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