Provider Demographics
NPI:1316415235
Name:BENJAMIN, TEAIRRA
Entity Type:Individual
Prefix:
First Name:TEAIRRA
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 1:10339 NE PRESCOTT ST APT 304
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-3476
Mailing Address - Country:US
Mailing Address - Phone:971-222-7195
Mailing Address - Fax:
Practice Address - Street 1:9115 SW OLSEN RD STE 100
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-6876
Practice Address - Country:US
Practice Address - Phone:510-882-6990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-08
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst