Basic Information
Provider Information
NPI: 1003006131
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BENDER
FirstName: THOMAS
MiddleName: S.
NamePrefix: MR.
NameSuffix:  
Credential: LPCC
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 4308 CARLISLE BLVD NE STE 209
Address2:  
City: ALBUQUERQUE
State: NM
PostalCode: 871074849
CountryCode: US
TelephoneNumber: (505) 681-1140
FaxNumber: 5058887943
Practice Location
Address1: 540 MAIN STREET
Address2: DELTA, CO 81416
City: DELTA
State: CO
PostalCode: 814168141
CountryCode: US
TelephoneNumber: 5056811140
FaxNumber: 5058887943
Other Information
ProviderEnumerationDate: 07/25/2007
LastUpdateDate: 03/17/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101Y00000X3377NMY Behavioral Health & Social Service ProvidersCounselor 

ID Information
IDTypeStateIssuerDescription
337701NMNEW MEXICO STATE COUNSELING LICENSEOTHER


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