Provider Demographics
NPI:1023143021
Name:DAVIS, KENNETH LEE (CPSW, CPSC, MSD, DD)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:LEE
Last Name:DAVIS
Suffix:
Gender:M
Credentials:CPSW, CPSC, MSD, DD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177B EL CERRO MISSION RD
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-7874
Mailing Address - Country:US
Mailing Address - Phone:505-240-2399
Mailing Address - Fax:
Practice Address - Street 1:184 UNSER BLVD NE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-4045
Practice Address - Country:US
Practice Address - Phone:505-896-0928
Practice Address - Fax:504-994-0209
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2014-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00056544101YM0800X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM44842Medicaid