Provider Demographics
NPI:1053472290
Name:BENEJAM, GUSTAVO R (PSYD)
Entity Type:Individual
Prefix:DR
First Name:GUSTAVO
Middle Name:R
Last Name:BENEJAM
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8185 TWIN LAKE DR
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33496-1919
Mailing Address - Country:US
Mailing Address - Phone:561-483-0220
Mailing Address - Fax:561-477-1538
Practice Address - Street 1:7301 W PALMETTO PARK RD STE 204A
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-3456
Practice Address - Country:US
Practice Address - Phone:561-368-9940
Practice Address - Fax:561-368-3255
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7387103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical