Provider Demographics
NPI:1851723183
Name:DAVIS, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
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 1:505 S MAIN ST
Mailing Address - Street 2:STE249
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-1206
Mailing Address - Country:US
Mailing Address - Phone:575-527-5884
Mailing Address - Fax:
Practice Address - Street 1:1990 E LOHMAN AVE
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-3172
Practice Address - Country:US
Practice Address - Phone:575-524-4813
Practice Address - Fax:575-524-4813
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-09
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-5358235Z00000X
NMSWB-2023-1363104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist