Healthcare Provider Details

I. General information

NPI: 1366068025
Provider Name (Legal Business Name): BENJAMIN FIELDS LSAA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2020
Last Update Date: 06/18/2020
Certification Date: 06/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1208 PASEO DEL PUEBLO NORTE
EL PRADO NM
87529-8752
US

IV. Provider business mailing address

PO BOX 3229
TAOS NM
87571-3229
US

V. Phone/Fax

Practice location:
  • Phone: 850-501-0562
  • Fax:
Mailing address:
  • Phone: 850-501-0562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCSA0211591
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: