Healthcare Provider Details

I. General information

NPI: 1497271142
Provider Name (Legal Business Name): EDWARD DAVIDSON LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2017
Last Update Date: 10/06/2025
Certification Date: 10/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 APACHE TRL
SANTA FE NM
87505-1470
US

IV. Provider business mailing address

3 APACHE TRL
SANTA FE NM
87505-1470
US

V. Phone/Fax

Practice location:
  • Phone: 505-603-1103
  • Fax: 505-438-6011
Mailing address:
  • Phone: 505-603-1103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM10037
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-12082
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: