Provider Demographics
NPI:1740373620
Name:DAVIES, PENNY J (PHD)
Entity type:Individual
Prefix:DR
First Name:PENNY
Middle Name:J
Last Name:DAVIES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:PENELOPE
Other - Middle Name:J
Other - Last Name:DAVIES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 1202
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:NM
Mailing Address - Zip Code:87567-1202
Mailing Address - Country:US
Mailing Address - Phone:505-753-6260
Mailing Address - Fax:505-753-6260
Practice Address - Street 1:600 E FAIRVIEW LN
Practice Address - Street 2:SUITE D
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2816
Practice Address - Country:US
Practice Address - Phone:505-753-6260
Practice Address - Fax:505-753-6260
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLPCC #0503101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1037113OtherCIGNA BEHAVIORAL HEALTH
NMB9533Medicaid
NMNM100145OtherVALUE OPTIONS