Provider Demographics
NPI:1235483041
Name:BENAVIDES, MOLLIE C
Entity Type:Individual
Prefix:
First Name:MOLLIE
Middle Name:C
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 1:1041 REDONDO AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-3928
Mailing Address - Country:US
Mailing Address - Phone:562-987-5722
Mailing Address - Fax:562-987-4586
Practice Address - Street 1:11501 DOLAN AVE
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241
Practice Address - Country:US
Practice Address - Phone:562-923-7894
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-31
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA190077AHNMedicaid