Healthcare Provider Details

I. General information

NPI: 1780883264
Provider Name (Legal Business Name): ERIC M. BANAGAY LISW, LADAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2007
Last Update Date: 05/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 E 21ST ST SUITE D
CLOVIS NM
88101-4443
US

IV. Provider business mailing address

921 E 21ST ST SUITE D
CLOVIS NM
88101-4443
US

V. Phone/Fax

Practice location:
  • Phone: 575-762-0212
  • Fax: 575-762-0660
Mailing address:
  • Phone: 575-762-0212
  • Fax: 575-762-0660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-06885
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0119781
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: