Provider Demographics
NPI:1174705610
Name:DAVENPORT, CHARLES ROBERT (PSYD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:ROBERT
Last Name:DAVENPORT
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 TAMIAMI TRL S
Mailing Address - Street 2:SUITE 603 A
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34285-3568
Mailing Address - Country:US
Mailing Address - Phone:941-321-1971
Mailing Address - Fax:941-866-0936
Practice Address - Street 1:1525 TAMIAMI TRL S
Practice Address - Street 2:SUITE 603 A
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-3568
Practice Address - Country:US
Practice Address - Phone:941-321-1971
Practice Address - Fax:941-866-0936
Is Sole Proprietor?:No
Enumeration Date:2007-11-27
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7978103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical