Provider Demographics
NPI:1699985259
Name:STACEY, CHARLES BENSON (LMFT)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:BENSON
Last Name:STACEY
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3510 MESSINA DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87402-4782
Mailing Address - Country:US
Mailing Address - Phone:832-630-3022
Mailing Address - Fax:
Practice Address - Street 1:3510 MESSINA DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87402-4782
Practice Address - Country:US
Practice Address - Phone:832-630-3022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2020-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4426106H00000X
NMCMF0068702106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM84254289Medicaid