Basic Information
| Provider Information | |||||||||
| NPI: | 1669560637 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVISON | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | S | ||||||||
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| NameSuffix: | |||||||||
| Credential: | LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6001 WHITEMAN DR NW | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871202196 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057171155 | ||||||||
| FaxNumber: | 5057171473 | ||||||||
| Practice Location | |||||||||
| Address1: | 6001 WHITEMAN DR NW | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871202196 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057171155 | ||||||||
| FaxNumber: | 5057171473 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 03/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 0087911 | NM | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | 0099731 | NM | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 202005549 | 01 | NM | PRESBYTERIAN HEALTH PLAN | OTHER | 46751386 | 05 | NM | MEDICAID |