Provider Demographics
NPI:1417281775
Name:BENECKE, KATHLEEN
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:BENECKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2891 PLAZA BLANCA
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-6516
Mailing Address - Country:US
Mailing Address - Phone:505-660-5209
Mailing Address - Fax:505-795-7638
Practice Address - Street 1:805 EARLY ST
Practice Address - Street 2:BLDG B STE 104 D
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-6516
Practice Address - Country:US
Practice Address - Phone:505-660-5209
Practice Address - Fax:505-795-7638
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-18
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCCMH0080461101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NME7436Medicaid