Provider Demographics
NPI:1043483167
Name:BENTON, CANDACE VIRGINIA (MSW)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:VIRGINIA
Last Name:BENTON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 S SAN PEDRO ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90013-2102
Mailing Address - Country:US
Mailing Address - Phone:310-743-5035
Mailing Address - Fax:
Practice Address - Street 1:1480 TERRACITA DR
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-1568
Practice Address - Country:US
Practice Address - Phone:310-743-5035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-09
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral