Provider Demographics
NPI:1013641521
Name:BENTON, SHANELLE AMBER (CSW / PSR INSTRUCTOR)
Entity Type:Individual
Prefix:
First Name:SHANELLE
Middle Name:AMBER
Last Name:BENTON
Suffix:
Gender:F
Credentials:CSW / PSR INSTRUCTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 SAKELARES BLVD
Mailing Address - Street 2:
Mailing Address - City:GRANTS
Mailing Address - State:NM
Mailing Address - Zip Code:87020-3819
Mailing Address - Country:US
Mailing Address - Phone:505-287-2273
Mailing Address - Fax:505-287-2403
Practice Address - Street 1:1040 SAKELARES BLVD
Practice Address - Street 2:
Practice Address - City:GRANTS
Practice Address - State:NM
Practice Address - Zip Code:87020-3819
Practice Address - Country:US
Practice Address - Phone:505-287-2273
Practice Address - Fax:505-287-2403
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-11
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
NM171M00000X171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst