Provider Demographics
NPI:1437502820
Name:BENITEZ, ISMERAI (CG60662276)
Entity Type:Individual
Prefix:
First Name:ISMERAI
Middle Name:
Last Name:BENITEZ
Suffix:
Gender:F
Credentials:CG60662276
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 E MEAD AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98903-3720
Mailing Address - Country:US
Mailing Address - Phone:509-453-1344
Mailing Address - Fax:509-453-2981
Practice Address - Street 1:918 E. MEAD AVE.
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98903
Practice Address - Country:US
Practice Address - Phone:509-453-1344
Practice Address - Fax:509-453-2981
Is Sole Proprietor?:No
Enumeration Date:2016-07-20
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60662276101YM0800X
175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACG60662276Medicaid