Provider Demographics
NPI:1578148805
Name:CODI BENOLOGA LICENSED CLINICAL SOCIAL WORKER INC
Entity Type:Organization
Organization Name:CODI BENOLOGA LICENSED CLINICAL SOCIAL WORKER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CODI
Authorized Official - Middle Name:JO
Authorized Official - Last Name:BENOLOGA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:480-221-4972
Mailing Address - Street 1:4195 N VIKING WAY STE 333
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90808-1466
Mailing Address - Country:US
Mailing Address - Phone:562-568-9005
Mailing Address - Fax:
Practice Address - Street 1:4195 N VIKING WAY STE 333
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90808-1466
Practice Address - Country:US
Practice Address - Phone:562-568-9005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-18
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center