Basic Information
| Provider Information | |||||||||
| NPI: | 1578870135 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BANDA | ||||||||
| FirstName: | ROCKY | ||||||||
| MiddleName: | EUGENE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 28220 | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875928220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054715006 | ||||||||
| FaxNumber: | 5058209220 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 PEACEFUL LN | ||||||||
| Address2: | |||||||||
| City: | CONVERSE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 781091007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102489077 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2010 | ||||||||
| LastUpdateDate: | 02/17/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 175T00000X | Y |
No ID Information.