Provider Demographics
NPI:1154550598
Name:DAVENPORT, BRANDON (COTA/L)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 SHEPARD ST
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28557-4250
Mailing Address - Country:US
Mailing Address - Phone:252-726-2587
Mailing Address - Fax:252-726-8611
Practice Address - Street 1:812 SHEPARD ST
Practice Address - Street 2:
Practice Address - City:MOREHEAD CITY
Practice Address - State:NC
Practice Address - Zip Code:28557-4250
Practice Address - Country:US
Practice Address - Phone:252-726-2587
Practice Address - Fax:252-726-8611
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-07
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7154224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant