1083768998 NPI number — WALTER PITTS DAVIS LMFT

Table of content: WALTER PITTS DAVIS LMFT (NPI 1083768998)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083768998 NPI number — WALTER PITTS DAVIS LMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIS
Provider First Name:
WALTER
Provider Middle Name:
PITTS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMFT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083768998
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4630 50TH ST
Provider Second Line Business Mailing Address:
SUITE 507
Provider Business Mailing Address City Name:
LUBBOCK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79414-3521
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-785-4801
Provider Business Mailing Address Fax Number:
806-771-8809

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4630 50TH ST
Provider Second Line Business Practice Location Address:
SUITE 507
Provider Business Practice Location Address City Name:
LUBBOCK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79414-3521
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-785-4801
Provider Business Practice Location Address Fax Number:
806-771-8809
Provider Enumeration Date:
01/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  3873 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00134B . This is a "BLUECROSSBLUESHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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