Provider Demographics
NPI:1114325248
Name:BENAVIDEZ, BEVERLY
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:BENAVIDEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2657 STONECROP RIDGE GRV
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910-4459
Mailing Address - Country:US
Mailing Address - Phone:719-291-8508
Mailing Address - Fax:
Practice Address - Street 1:2657 STONECROP RIDGE GRV
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-4459
Practice Address - Country:US
Practice Address - Phone:719-291-8508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-04
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171R00000X, 174H00000X, 246Z00000X
CO619004171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other
No171R00000XOther Service ProvidersInterpreter
No171W00000XOther Service ProvidersContractor
No174H00000XOther Service ProvidersHealth Educator