Provider Demographics
NPI:1801003660
Name:BENALLY, MARY E (LADAC, LISAC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:E
Last Name:BENALLY
Suffix:
Gender:F
Credentials:LADAC, LISAC
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 102
Mailing Address - Street 2:
Mailing Address - City:WATERFLOW
Mailing Address - State:NM
Mailing Address - Zip Code:87421-0102
Mailing Address - Country:US
Mailing Address - Phone:505-368-1050
Mailing Address - Fax:505-368-1055
Practice Address - Street 1:HWY 491 N., PINON ST.
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:505-368-1055
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3814101YA0400X
AZ11490101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)