Healthcare Provider Details

I. General information

NPI: 1851844229
Provider Name (Legal Business Name): AMANDA BENTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2016
Last Update Date: 03/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2504 CAMINO ENTRADA
SANTA FE NM
87507-4851
US

IV. Provider business mailing address

4300 SIERRA BLANCA
SANTA FE NM
87507-1631
US

V. Phone/Fax

Practice location:
  • Phone: 505-471-5006
  • Fax:
Mailing address:
  • Phone: 432-349-9123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: