Provider Demographics
NPI:1265422703
Name:DAVIS, ROSALIE (PHD, RXP)
Entity type:Individual
Prefix:MS
First Name:ROSALIE
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PHD, RXP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 LOUISIANA BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-2734
Mailing Address - Country:US
Mailing Address - Phone:505-881-0404
Mailing Address - Fax:505-881-4654
Practice Address - Street 1:3003 LOUISIANA BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-2734
Practice Address - Country:US
Practice Address - Phone:505-881-0404
Practice Address - Fax:505-881-4654
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0009103TP0016X
NM137103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMN7893Medicaid
NMN0789Medicaid
NMN0789Medicaid