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General NPI Number Information
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NPI Number | 1780883264
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Entity Type | Individual
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Provider Name | ERIC M. BANAGAY LISW, LADAC
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Gender | Male
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Dates
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Enumeration Date | 07/13/2007
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Last Update Date | 05/15/2015
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Provider Practice Location Address
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Address Line | 921 E 21ST ST SUITE D
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City | CLOVIS
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State | NM
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Zip | 88101-4443
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Country | US
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Telephone | 575-762-0212
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Fax | 575-762-0660
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Provider Business Mailing Address
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Address Line | 921 E 21ST ST SUITE D
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City | CLOVIS
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State | NM
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Zip | 88101-4443
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Country | US
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Telephone | 575-762-0212
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Fax | 575-762-0660
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | I-06885
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 0119781
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License Number State | NM
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