Basic Information
Provider Information | |||||||||
NPI: | 1023143021 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DAVIS | ||||||||
FirstName: | KENNETH | ||||||||
MiddleName: | LEE | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CPSW, CPSC, MSD, DD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 177B EL CERRO MISSION RD | ||||||||
Address2: |   | ||||||||
City: | LOS LUNAS | ||||||||
State: | NM | ||||||||
PostalCode: | 870317874 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5052402399 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 184 UNSER BLVD NE | ||||||||
Address2: |   | ||||||||
City: | RIO RANCHO | ||||||||
State: | NM | ||||||||
PostalCode: | 871244045 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5058960928 | ||||||||
FaxNumber: | 5049940209 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/22/2007 | ||||||||
LastUpdateDate: | 04/25/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | RC00056544 | WA | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 171M00000X |   |   | Y |   | Other Service Providers | Case Manager/Care Coordinator |   |
ID Information
ID | Type | State | Issuer | Description | 44842 | 05 | NM |   | MEDICAID |