Healthcare Provider Details

I. General information

NPI: 1417545765
Provider Name (Legal Business Name): CAROLYN DAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2021
Last Update Date: 08/04/2025
Certification Date: 08/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 LOS ARBOLES AVE NE
ALBUQUERQUE NM
87107-1943
US

IV. Provider business mailing address

3301 LOS ARBOLES AVE NE
ALBUQUERQUE NM
87107-1943
US

V. Phone/Fax

Practice location:
  • Phone: 505-800-7092
  • Fax: 505-888-2851
Mailing address:
  • Phone: 505-888-7092
  • Fax: 505-888-2851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCTB-2025-0512
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: