Healthcare Provider Details

I. General information

NPI: 1013641521
Provider Name (Legal Business Name): SHANELLE AMBER BENTON CSW / PSR INSTRUCTOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2022
Last Update Date: 07/20/2022
Certification Date: 07/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 SAKELARES BLVD
GRANTS NM
87020-3819
US

IV. Provider business mailing address

1040 SAKELARES BLVD
GRANTS NM
87020-3819
US

V. Phone/Fax

Practice location:
  • Phone: 505-287-2273
  • Fax: 505-287-2403
Mailing address:
  • Phone: 505-287-2273
  • Fax: 505-287-2403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number171M00000X
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: