Provider Demographics
NPI:1487638714
Name:BENAVIDES JR., ROBERT (EDD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:BENAVIDES JR.
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2455 BENNETT VALLEY RD
Mailing Address - Street 2:SUITE 210 C
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-5663
Mailing Address - Country:US
Mailing Address - Phone:707-542-2081
Mailing Address - Fax:707-542-2082
Practice Address - Street 1:2455 BENNETT VALLEY RD
Practice Address - Street 2:SUITE 210 C
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-5663
Practice Address - Country:US
Practice Address - Phone:707-542-2081
Practice Address - Fax:707-542-2082
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 11363103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PL113630Medicare ID - Type Unspecified
CA4269907Medicare UPIN