Provider Demographics
NPI:1366068025
Name:FIELDS, BENJAMIN (LSAA)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:FIELDS
Suffix:
Gender:M
Credentials:LSAA
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 3229
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-3229
Mailing Address - Country:US
Mailing Address - Phone:850-501-0562
Mailing Address - Fax:
Practice Address - Street 1:1208 PASEO DEL PUEBLO NORTE
Practice Address - Street 2:
Practice Address - City:EL PRADO
Practice Address - State:NM
Practice Address - Zip Code:87529-8752
Practice Address - Country:US
Practice Address - Phone:850-501-0562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-18
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCSA0211591101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)