Provider Demographics
NPI:1639470412
Name:BENAVIDES, MARIBEL (EIS)
Entity Type:Individual
Prefix:MRS
First Name:MARIBEL
Middle Name:
Last Name:BENAVIDES
Suffix:
Gender:F
Credentials:EIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 725
Mailing Address - Street 2:
Mailing Address - City:LYTLE
Mailing Address - State:TX
Mailing Address - Zip Code:78052-0725
Mailing Address - Country:US
Mailing Address - Phone:210-357-0395
Mailing Address - Fax:830-709-5493
Practice Address - Street 1:19965 FM 3175
Practice Address - Street 2:
Practice Address - City:LYTLE
Practice Address - State:TX
Practice Address - Zip Code:78052-3481
Practice Address - Country:US
Practice Address - Phone:210-357-0395
Practice Address - Fax:830-709-5493
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-09
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX990012222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX99-0012OtherLICENSE OTHER