Provider Demographics
NPI:1417603010
Name:BENETICH, GINA
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:BENETICH
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 1:42720 N 44TH DR
Mailing Address - Street 2:
Mailing Address - City:NEW RIVER
Mailing Address - State:AZ
Mailing Address - Zip Code:85087-5917
Mailing Address - Country:US
Mailing Address - Phone:219-743-0439
Mailing Address - Fax:
Practice Address - Street 1:20402 N 15TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-3699
Practice Address - Country:US
Practice Address - Phone:623-445-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-23
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBEH-000235103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst