Provider Demographics
NPI:1407460231
Name:BEGAY, MANASSEH CODY
Entity Type:Individual
Prefix:
First Name:MANASSEH
Middle Name:CODY
Last Name:BEGAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2529 RIO VISTA WAY
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-4562
Mailing Address - Country:US
Mailing Address - Phone:505-608-4107
Mailing Address - Fax:
Practice Address - Street 1:5101 COLLEGE BLVD
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87402-4709
Practice Address - Country:US
Practice Address - Phone:505-787-2518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-31
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCAD0195421101YA0400X
NMX112801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty