Provider Demographics
NPI:1063858702
Name:DAVIS, REBECCA KATHLEEN (LCSW)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:KATHLEEN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 CARLISLE BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-4808
Mailing Address - Country:US
Mailing Address - Phone:505-717-1332
Mailing Address - Fax:
Practice Address - Street 1:4201 CARLISLE BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-4808
Practice Address - Country:US
Practice Address - Phone:505-717-1332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-21
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-100021041C0700X
NMC-110101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical