Healthcare Provider Details

I. General information

NPI: 1215418983
Provider Name (Legal Business Name): JOHN THOMAS DAVIS LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2018
Last Update Date: 03/21/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DR SE
ALBUQUERQUE NM
87108
US

IV. Provider business mailing address

4220 PENELOPE PLACE NE
ALBUQUERQUE NM
87109
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-1711
  • Fax: 774-441-6284
Mailing address:
  • Phone: 505-934-4478
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number119237
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-05771
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: