Provider Demographics
NPI:1457637191
Name:BENVENUTI, BRENNA M
Entity Type:Individual
Prefix:
First Name:BRENNA
Middle Name:M
Last Name:BENVENUTI
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 1:525 HALF HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:DIX HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11746-5828
Mailing Address - Country:US
Mailing Address - Phone:631-592-3000
Mailing Address - Fax:
Practice Address - Street 1:600 S SERVICE RD
Practice Address - Street 2:
Practice Address - City:DIX HILLS
Practice Address - State:NY
Practice Address - Zip Code:11746-6015
Practice Address - Country:US
Practice Address - Phone:631-592-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-26
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014063235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist