Provider Demographics
NPI:1578753505
Name:BENTON, GENORA MICHELLE
Entity Type:Individual
Prefix:MRS
First Name:GENORA
Middle Name:MICHELLE
Last Name:BENTON
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 1:10209 N 22ND ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612
Mailing Address - Country:US
Mailing Address - Phone:813-975-0280
Mailing Address - Fax:813-631-1429
Practice Address - Street 1:10209 N 22ND ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612
Practice Address - Country:US
Practice Address - Phone:813-975-0280
Practice Address - Fax:813-631-1429
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-26
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106E00000X, 253Z00000X, 372500000X, 372600000X, 385H00000X, 385HR2065X
FL6923844372600000X
FL692384496372600000X
FL235260376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemakerGroup - Multi-Specialty
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No253Z00000XAgenciesIn Home Supportive Care
No372500000XNursing Service Related ProvidersChore Provider
No372600000XNursing Service Related ProvidersAdult Companion
No385H00000XRespite Care FacilityRespite CareGroup - Multi-Specialty
No385HR2065XRespite Care FacilityRespite CareRespite Care, Physical Disabilities, ChildGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL692384496Medicaid
FL692384498Medicaid