Provider Demographics
NPI:1265006308
Name:BENJAMIN, AUTUMN
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:BENJAMIN
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 1:9240 BELTWAY 8 UNIT 110
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77396
Mailing Address - Country:US
Mailing Address - Phone:855-782-7822
Mailing Address - Fax:
Practice Address - Street 1:9240 BELTWAY 8 UNIT 110
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77396
Practice Address - Country:US
Practice Address - Phone:855-782-7822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-13
Last Update Date:2022-08-02
Deactivation Date:2021-09-28
Deactivation Code:
Reactivation Date:2022-07-19
Provider Licenses
StateLicense IDTaxonomies
TX106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician