Provider Demographics
NPI:1639358971
Name:DAVIS, MARTHA MARIE
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:MARIE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5959 GATEWAY BLVD W
Mailing Address - Street 2:SUITE 329
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-3331
Mailing Address - Country:US
Mailing Address - Phone:915-799-9552
Mailing Address - Fax:
Practice Address - Street 1:5959 GATEWAY BLVD W
Practice Address - Street 2:SUITE 100
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-3331
Practice Address - Country:US
Practice Address - Phone:915-799-9552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-02
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC421504Medicaid
SC421504Medicaid