Provider Demographics
NPI:1619729522
Name:BENEDICT, ALYSIA
Entity Type:Individual
Prefix:
First Name:ALYSIA
Middle Name:
Last Name:BENEDICT
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 1:104 HOMESTEAD LN
Mailing Address - Street 2:
Mailing Address - City:MOYOCK
Mailing Address - State:NC
Mailing Address - Zip Code:27958-8807
Mailing Address - Country:US
Mailing Address - Phone:719-433-0811
Mailing Address - Fax:
Practice Address - Street 1:104 HOMESTEAD LN
Practice Address - Street 2:
Practice Address - City:MOYOCK
Practice Address - State:NC
Practice Address - Zip Code:27958-8807
Practice Address - Country:US
Practice Address - Phone:719-433-0811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-03
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-24-335754106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician