Provider Demographics
NPI:1043321391
Name:BENEDETTO, MARYELLEN (LCSW)
Entity Type:Individual
Prefix:
First Name:MARYELLEN
Middle Name:
Last Name:BENEDETTO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 MAPLE CT STE 101
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-3556
Mailing Address - Country:US
Mailing Address - Phone:805-644-1831
Mailing Address - Fax:805-644-5114
Practice Address - Street 1:260 MAPLE CT STE 101
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-3556
Practice Address - Country:US
Practice Address - Phone:805-644-1831
Practice Address - Fax:805-644-5114
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 50251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMBSW5025Medicare UPIN
CASW5025Medicare ID - Type Unspecified