Provider Demographics
NPI:1346741451
Name:BENALLY, LUCRECIA
Entity Type:Individual
Prefix:
First Name:LUCRECIA
Middle Name:
Last Name:BENALLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 E APACHE ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-6925
Mailing Address - Country:US
Mailing Address - Phone:505-326-2012
Mailing Address - Fax:505-326-2939
Practice Address - Street 1:PINION & COTTONWOOD DR. BUILDING 2308
Practice Address - Street 2:
Practice Address - City:SHIPROCK
Practice Address - State:NM
Practice Address - Zip Code:87420
Practice Address - Country:US
Practice Address - Phone:505-368-1050
Practice Address - Fax:505-368-1437
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-23
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0169541101YA0400X
NMCSA0223561101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)