Provider Demographics
NPI:1659123974
Name:BENABOURA, LYNETTE CHARRISE
Entity Type:Individual
Prefix:
First Name:LYNETTE
Middle Name:CHARRISE
Last Name:BENABOURA
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 1:5341 OLIVE AVE
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34231-2511
Mailing Address - Country:US
Mailing Address - Phone:941-914-7501
Mailing Address - Fax:
Practice Address - Street 1:5341 OLIVE AVE
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34231-2511
Practice Address - Country:US
Practice Address - Phone:941-914-7501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-02
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty