Basic Information
| Provider Information | |||||||||
| NPI: | 1013641521 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENTON | ||||||||
| FirstName: | SHANELLE | ||||||||
| MiddleName: | AMBER | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CSW / PSR INSTRUCTOR | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1040 SAKELARES BLVD | ||||||||
| Address2: | |||||||||
| City: | GRANTS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870203819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052872273 | ||||||||
| FaxNumber: | 5052872403 | ||||||||
| Practice Location | |||||||||
| Address1: | 1040 SAKELARES BLVD | ||||||||
| Address2: | |||||||||
| City: | GRANTS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870203819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052872273 | ||||||||
| FaxNumber: | 5052872403 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2022 | ||||||||
| LastUpdateDate: | 07/20/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 171M00000X | 171M00000X | NM | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.