Provider Demographics
NPI:1114328176
Name:BENAVIDES, SHELLEY SUZANN
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:SUZANN
Last Name:BENAVIDES
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 1:2501 S 28TH ST
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79605-6335
Mailing Address - Country:US
Mailing Address - Phone:325-201-4280
Mailing Address - Fax:325-232-6304
Practice Address - Street 1:2501 S 28TH ST
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79605-6335
Practice Address - Country:US
Practice Address - Phone:325-201-4280
Practice Address - Fax:325-232-6304
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-09
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency