Provider Demographics
NPI:1003273558
Name:BENAVIDES, CELINA CONCEPCION (LPT)
Entity Type:Individual
Prefix:
First Name:CELINA
Middle Name:CONCEPCION
Last Name:BENAVIDES
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 W. BASELINE RD
Mailing Address - Street 2:BOX 400
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750
Mailing Address - Country:US
Mailing Address - Phone:909-833-2986
Mailing Address - Fax:
Practice Address - Street 1:14677 MERRILL AVE
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335
Practice Address - Country:US
Practice Address - Phone:951-643-2340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-27
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT36261167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALPT36261OtherBVNPT