Provider Demographics
NPI:1609118165
Name:DOMINIQUE BENAVIDEZ PSYCHOLOGY CONSULTANT AND ASSOCIATES
Entity Type:Organization
Organization Name:DOMINIQUE BENAVIDEZ PSYCHOLOGY CONSULTANT AND ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOMINIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:BENAVIDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:310-373-0800
Mailing Address - Street 1:904 SILVER SPUR RD
Mailing Address - Street 2:#297
Mailing Address - City:ROLLING HILLS ESTATES
Mailing Address - State:CA
Mailing Address - Zip Code:90274-3800
Mailing Address - Country:US
Mailing Address - Phone:310-373-0800
Mailing Address - Fax:310-373-0880
Practice Address - Street 1:24520 HAWTHORNE BLVD
Practice Address - Street 2:STE. 216
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-6800
Practice Address - Country:US
Practice Address - Phone:310-373-0800
Practice Address - Fax:310-373-0880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-22
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY22620103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACC615AOtherPTAN