Provider Information for 1497271142
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EDWARD DAVIDSON LICSW
Sex: Male
NPI: 1497271142
Last Updated: 2022-12-13
Certification Date: 2022-12-09
Certification Date: 2022-12-09
Details
Name | Value | ||||||||||||||||
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NPI | 1497271142 | ||||||||||||||||
Enumeration Date | 2017-08-15 | ||||||||||||||||
NPI Type | NPI-1 Individual | ||||||||||||||||
Sole Proprietor | YES | ||||||||||||||||
Status | Active | ||||||||||||||||
Mailing Address | 100B ESPANOLA NM ESPANOLA, NM 87532-3373 United States Phone: 505-603-1103 | Fax: | ||||||||||||||||
Primary Practice Address | 100B ESPANOLA NM ESPANOLA, NM 87532-8753 United States Phone: 505-603-1103 | Fax:505-438-6011 | ||||||||||||||||
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