Provider Demographics
NPI:1609379171
Name:BENAVIDEZ, AMANDA SUE (LPC)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:SUE
Last Name:BENAVIDEZ
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1336
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78374-2213
Mailing Address - Country:US
Mailing Address - Phone:361-777-3991
Mailing Address - Fax:361-777-0610
Practice Address - Street 1:1621 EAST CORRAL
Practice Address - Street 2:
Practice Address - City:KINGSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78363
Practice Address - Country:US
Practice Address - Phone:361-592-6481
Practice Address - Fax:361-362-0695
Is Sole Proprietor?:No
Enumeration Date:2018-03-12
Last Update Date:2018-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX74828101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health