Provider Demographics
NPI:1578761680
Name:BENTON, ALICE ELIZABETH (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ALICE
Middle Name:ELIZABETH
Last Name:BENTON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:ALICE
Other - Middle Name:ELIZABETH
Other - Last Name:OLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:123 S ALVARADO ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-2201
Mailing Address - Country:US
Mailing Address - Phone:213-989-7700
Mailing Address - Fax:213-989-7702
Practice Address - Street 1:123 S ALVARADO ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-2201
Practice Address - Country:US
Practice Address - Phone:213-989-7700
Practice Address - Fax:213-989-7702
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CAPSY23516103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05-1007OtherMEDICARE ID
CAFHC71005FMedicaid
CAFHC70567FMedicaid
CA05-1023OtherMEDICARE ID