Provider Demographics
NPI:1386214849
Name:BENEDICT, PHOEBE MARIE
Entity Type:Individual
Prefix:
First Name:PHOEBE
Middle Name:MARIE
Last Name:BENEDICT
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 1:1100 NORTH DST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92410-3523
Mailing Address - Country:US
Mailing Address - Phone:909-888-6956
Mailing Address - Fax:909-521-7113
Practice Address - Street 1:1100 NORTH DST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92410-3523
Practice Address - Country:US
Practice Address - Phone:909-884-0840
Practice Address - Fax:909-521-7113
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-28
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)