Provider Demographics
NPI:1659565455
Name:KROLL, BENJAMIN M (SW)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:M
Last Name:KROLL
Suffix:
Gender:M
Credentials:SW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2220 RAYMAC RD SW
Mailing Address - Street 2:POLK MS
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87105-6843
Mailing Address - Country:US
Mailing Address - Phone:505-877-6494
Mailing Address - Fax:
Practice Address - Street 1:2220 RAYMAC RD SW
Practice Address - Street 2:POLK MS
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87105-6843
Practice Address - Country:US
Practice Address - Phone:505-877-6494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-05
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI 45171041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNON ASSIGNED YETMedicaid