Provider Demographics
NPI:1568748846
Name:BENAVIDES, MARISA R (MS, RD, LD)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:R
Last Name:BENAVIDES
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6801 MCPHERSON RD
Mailing Address - Street 2:SUITE #226
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78041-6402
Mailing Address - Country:US
Mailing Address - Phone:956-717-0113
Mailing Address - Fax:956-717-2070
Practice Address - Street 1:6801 MCPHERSON RD
Practice Address - Street 2:SUITE #226
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041-6402
Practice Address - Country:US
Practice Address - Phone:956-717-0113
Practice Address - Fax:956-717-2070
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-31
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT05576133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal