Provider Demographics
NPI:1417754193
Name:DAVENPORT, HOLLY
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:DAVENPORT
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1073 E 146TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44110-3315
Mailing Address - Country:US
Mailing Address - Phone:216-738-2265
Mailing Address - Fax:
Practice Address - Street 1:612 E 185TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44119-1766
Practice Address - Country:US
Practice Address - Phone:216-659-7610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-28
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRT692702171M00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator