Healthcare Provider Details

I. General information

NPI: 1821794264
Provider Name (Legal Business Name): SHANNON MARIE BENALLY LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2023
Last Update Date: 02/07/2023
Certification Date: 02/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 CORNELL DR SE BLDG 73,
ALBUQUERQUE NM
87131-0001
US

IV. Provider business mailing address

PO BOX 531
WATERFLOW NM
87421-0531
US

V. Phone/Fax

Practice location:
  • Phone: 505-277-3136
  • Fax:
Mailing address:
  • Phone: 505-493-7533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCTB-2022-0975
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: