Healthcare Provider Details

I. General information

NPI: 1679710677
Provider Name (Legal Business Name): ALLISON BENTON GOSS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2009
Last Update Date: 03/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 CARLISLE BLVD NE SUITE A
ALBUQUERQUE NM
87110-5667
US

IV. Provider business mailing address

1400 CARLISLE BLVD NE SUITE A
ALBUQUERQUE NM
87110-5667
US

V. Phone/Fax

Practice location:
  • Phone: 505-266-2997
  • Fax: 505-266-3063
Mailing address:
  • Phone: 505-266-2997
  • Fax: 505-266-3063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ALLISON BENTON GOSS
Title or Position: MEMBER
Credential: LISW
Phone: 505-266-2997