MEDICARE: MS. MARTHA WALTER DAVIS LPCC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	LPCC1977	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	NM00R45L	OTHER	NM	BCBS OF NM
2	NM101518	OTHER	NM	VALUE OPTIONS

General Provider Information

NPI Number	:	1710935275
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARTHA WALTER DAVIS LPCC

Provider Business Mailing Address
First Line	:	1751 OLD PECOS TRAIL
Second Line	:	SUITE G
City	:	SANTA FE
State	:	NM
Zip	:	87505-4706
Country	:	US
Telephone Number	:	505-989-8199
Fax Number	:

Provider Business Practice Location Address
First Line	:	1751 OLD PECOS TRAIL
Second Line	:	SUITE G
City	:	SANTA FE
State	:	NM
Zip	:	87505-4706
Country	:	US
Telephone Number	:	505-989-8199
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/05/2006
Last Update Date	:	01/27/2015

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