Provider Demographics
NPI:1114010634
Name:BENAVIDEZ, ANGELICA KATHLEEN (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:ANGELICA
Middle Name:KATHLEEN
Last Name:BENAVIDEZ
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:836 MARIE PARK DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87123-1719
Mailing Address - Country:US
Mailing Address - Phone:505-362-3909
Mailing Address - Fax:505-323-5392
Practice Address - Street 1:836 MARIE PARK DR NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87123-1719
Practice Address - Country:US
Practice Address - Phone:505-362-3909
Practice Address - Fax:505-323-5392
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2741235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMB7988Medicaid