Provider Demographics
NPI:1780883264
Name:BANAGAY, ERIC M (LISW, LADAC)
Entity type:Individual
Prefix:MR
First Name:ERIC
Middle Name:M
Last Name:BANAGAY
Suffix:
Gender:M
Credentials:LISW, LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
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Mailing Address - Street 1:921 E 21ST ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-4443
Mailing Address - Country:US
Mailing Address - Phone:575-762-0212
Mailing Address - Fax:575-762-0660
Practice Address - Street 1:921 E 21ST ST
Practice Address - Street 2:SUITE D
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-4443
Practice Address - Country:US
Practice Address - Phone:575-762-0212
Practice Address - Fax:575-762-0660
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-068851041C0700X
NM0119781101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM13683527Medicaid