Healthcare Provider Details

I. General information

NPI: 1710935275
Provider Name (Legal Business Name): MARTHA WALTER DAVIS LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 01/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1751 OLD PECOS TRAIL SUITE G
SANTA FE NM
87505-4706
US

IV. Provider business mailing address

1751 OLD PECOS TRAIL SUITE G
SANTA FE NM
87505-4706
US

V. Phone/Fax

Practice location:
  • Phone: 505-989-8199
  • Fax:
Mailing address:
  • Phone: 505-989-8199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPCC1977
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: