Provider Demographics
NPI:1497110837
Name:BENAVIDEZ, ANTHONY
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:BENAVIDEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2190 W PASEO REDONDO
Mailing Address - Street 2:
Mailing Address - City:ORACLE
Mailing Address - State:AZ
Mailing Address - Zip Code:85623-7007
Mailing Address - Country:US
Mailing Address - Phone:520-591-5947
Mailing Address - Fax:
Practice Address - Street 1:2190 W PASEO REDONDO
Practice Address - Street 2:
Practice Address - City:ORACLE
Practice Address - State:AZ
Practice Address - Zip Code:85623-7007
Practice Address - Country:US
Practice Address - Phone:520-591-5947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-30
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD03402227103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst