Provider Demographics
NPI:1063845097
Name:BENFORD, DERRELL
Entity Type:Individual
Prefix:
First Name:DERRELL
Middle Name:
Last Name:BENFORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89101-1904
Mailing Address - Country:US
Mailing Address - Phone:702-463-0110
Mailing Address - Fax:702-463-0166
Practice Address - Street 1:600 N 1ST ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89101-1904
Practice Address - Country:US
Practice Address - Phone:702-463-0110
Practice Address - Fax:702-463-0166
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-13
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst