Provider Demographics
NPI:1619304839
Name:BENJAMIN, LAILA (MA, QMHP)
Entity Type:Individual
Prefix:
First Name:LAILA
Middle Name:
Last Name:BENJAMIN
Suffix:
Gender:F
Credentials:MA, QMHP
Other - Prefix:
Other - First Name:LAILA
Other - Middle Name:
Other - Last Name:AYI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:336 CALLAN AVE
Mailing Address - Street 2:SUITE 2 WEST
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-3579
Mailing Address - Country:US
Mailing Address - Phone:847-859-6085
Mailing Address - Fax:
Practice Address - Street 1:336 CALLAN AVE
Practice Address - Street 2:SUITE 2 WEST
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-3579
Practice Address - Country:US
Practice Address - Phone:847-859-6085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-02
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL12554686OtherCAQH