Provider Demographics
NPI:1093425043
Name:BENALLYSON, ELIJAH COLE (PSR AIDE)
Entity Type:Individual
Prefix:
First Name:ELIJAH
Middle Name:COLE
Last Name:BENALLYSON
Suffix:
Gender:M
Credentials:PSR AIDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-5638
Mailing Address - Country:US
Mailing Address - Phone:505-634-6999
Mailing Address - Fax:
Practice Address - Street 1:1001 W BROADWAY
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5638
Practice Address - Country:US
Practice Address - Phone:505-634-6999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-30
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst