Provider Demographics
NPI:1710935275
Name:DAVIS, MARTHA WALTER (LPCC)
Entity Type:Individual
Prefix:MS
First Name:MARTHA
Middle Name:WALTER
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1751 OLD PECOS TRAIL
Mailing Address - Street 2:SUITE G
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4706
Mailing Address - Country:US
Mailing Address - Phone:505-989-8199
Mailing Address - Fax:
Practice Address - Street 1:1751 OLD PECOS TRAIL
Practice Address - Street 2:SUITE G
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4706
Practice Address - Country:US
Practice Address - Phone:505-989-8199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLPCC1977101YP2500X
NMLMFT2844106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM00R45LOtherBCBS OF NM
NMNM101518OtherVALUE OPTIONS