Provider Demographics
NPI:1275660524
Name:BENVIN, STACY
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:BENVIN
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 1:12635 S 35TH PL
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-3519
Mailing Address - Country:US
Mailing Address - Phone:480-219-8719
Mailing Address - Fax:480-219-8719
Practice Address - Street 1:12635 S 35TH PL
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-3519
Practice Address - Country:US
Practice Address - Phone:480-219-8719
Practice Address - Fax:480-219-8719
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2012-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP0400235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0140920OtherBLUE CROSS BLUE SHIELD
AZ345018Medicaid
AZ345018Medicaid