Provider Demographics
NPI:1114525482
Name:BENSON, MACEY BREANNE
Entity Type:Individual
Prefix:
First Name:MACEY
Middle Name:BREANNE
Last Name:BENSON
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 1:4050 S ARIZONA AVE STE L-1
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85248-4599
Mailing Address - Country:US
Mailing Address - Phone:480-812-2110
Mailing Address - Fax:
Practice Address - Street 1:4050 S ARIZONA AVE STE L-1
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85248-4599
Practice Address - Country:US
Practice Address - Phone:480-812-2110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician