Provider Demographics
NPI:1518268242
Name:BENALLI, ALFRED B
Entity Type:Individual
Prefix:
First Name:ALFRED
Middle Name:B
Last Name:BENALLI
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:PO BOX 3338
Mailing Address - Street 2:
Mailing Address - City:CANONCITO
Mailing Address - State:NM
Mailing Address - Zip Code:87026-3338
Mailing Address - Country:US
Mailing Address - Phone:505-908-2517
Mailing Address - Fax:505-908-2572
Practice Address - Street 1:129 MEDICINE HORSE DRIVE
Practice Address - Street 2:
Practice Address - City:TOHAJIILEE
Practice Address - State:NM
Practice Address - Zip Code:87026
Practice Address - Country:US
Practice Address - Phone:505-908-2307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-11
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3854101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)