Provider Demographics
NPI:1154073187
Name:DAVENPORT-ROSE, REBECCA L
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:DAVENPORT-ROSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:326 N RIDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33870-7205
Mailing Address - Country:US
Mailing Address - Phone:863-576-9907
Mailing Address - Fax:
Practice Address - Street 1:326 N RIDGEWOOD DR STE 210
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33870-7205
Practice Address - Country:US
Practice Address - Phone:863-576-9907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-20
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-21-192930106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty