Healthcare Provider Details

I. General information

NPI: 1346741451
Provider Name (Legal Business Name): LUCRECIA BENALLY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2018
Last Update Date: 06/29/2022
Certification Date: 06/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PINION & COTTONWOOD DR. BUILDING 2308
SHIPROCK NM
87420
US

IV. Provider business mailing address

607 E APACHE ST
FARMINGTON NM
87401-6925
US

V. Phone/Fax

Practice location:
  • Phone: 505-368-1050
  • Fax: 505-368-1437
Mailing address:
  • Phone: 505-326-2012
  • Fax: 505-326-2939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0169541
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCSA0223561
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: