Healthcare Provider Details

I. General information

NPI: 1972551398
Provider Name (Legal Business Name): JUSTIN C. BENEDICT PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 11/20/2023
Certification Date: 11/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 S MIRANDA ST
LAS CRUCES NM
88005-2823
US

IV. Provider business mailing address

385 CALLE DE ALEGRA STE A
LAS CRUCES NM
88005-3423
US

V. Phone/Fax

Practice location:
  • Phone: 575-647-2800
  • Fax: 575-647-2898
Mailing address:
  • Phone: 575-526-1105
  • Fax: 575-524-4266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1118035
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number75195
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number8790
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: