MEDICARE: LA BENALDE INTERGRATIVE MENTAL & BEHAVIORAL HEALTH , PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	101YM0800X	Mental Health Counselor
2	103T00000X	Psychologist
3	103TC0700X	Clinical Psychologist
4	363LP0808X	Psychiatric/Mental Health Nurse Practitioner
5	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1558102954
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LA BENALDE INTERGRATIVE MENTAL & BEHAVIORAL HEALTH , PLLC

Provider Business Mailing Address
First Line	:	11232 IVANHOE DR
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79936-2207
Country	:	US
Telephone Number	:	915-799-8416
Fax Number	:	915-242-0400

Provider Business Practice Location Address
First Line	:	6044 GATEWAY BLVD E STE 444
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79905-2037
Country	:	US
Telephone Number	:	915-203-8832
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JUSTIN C BENEDICT
Credential	:
Telephone Number	:	915-203-8832

Provider Enumeration Date	:	06/03/2024
Last Update Date	:	06/03/2024

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