Healthcare Provider Details

I. General information

NPI: 1417281775
Provider Name (Legal Business Name): KATHLEEN BENECKE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2009
Last Update Date: 10/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 EARLY ST BLDG B STE 104 D
SANTA FE NM
87505-6516
US

IV. Provider business mailing address

2891 PLAZA BLANCA
SANTA FE NM
87507-6516
US

V. Phone/Fax

Practice location:
  • Phone: 505-660-5209
  • Fax: 505-795-7638
Mailing address:
  • Phone: 505-660-5209
  • Fax: 505-795-7638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCCMH0080461
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: