Provider Demographics
NPI:1417066457
Name:BENHAM, MARILYN KAY (BCBA)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:KAY
Last Name:BENHAM
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1044 ROCKY BAYOU DR
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-2347
Mailing Address - Country:US
Mailing Address - Phone:850-678-6773
Mailing Address - Fax:
Practice Address - Street 1:1044 ROCKY BAYOU DR
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-2347
Practice Address - Country:US
Practice Address - Phone:850-678-6773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7600801Medicaid