Provider Demographics
NPI:1497271142
Name:DAVIDSON, EDWARD (LICSW)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100B ESPANOLA NM
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-3373
Mailing Address - Country:US
Mailing Address - Phone:505-603-1103
Mailing Address - Fax:
Practice Address - Street 1:100B ESPANOLA NM
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-8753
Practice Address - Country:US
Practice Address - Phone:505-603-1103
Practice Address - Fax:505-438-6011
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-15
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM10037104100000X
171M00000X
NMM-10037104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care Coordinator