Provider Demographics
NPI:1144751579
Name:BENAVIDES, CARLOS FABRICIO (ASW112732)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:FABRICIO
Last Name:BENAVIDES
Suffix:
Gender:M
Credentials:ASW112732
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 E WARDLOW RD
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-4628
Mailing Address - Country:US
Mailing Address - Phone:310-523-9500
Mailing Address - Fax:310-225-2725
Practice Address - Street 1:850 E WARDLOW RD
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-4628
Practice Address - Country:US
Practice Address - Phone:562-981-9392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-27
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW112732101YM0800X, 1041C0700X
CAASW76018101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health