Provider Demographics
NPI:1679039473
Name:BENSON, SYNETRA
Entity Type:Individual
Prefix:
First Name:SYNETRA
Middle Name:
Last Name:BENSON
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 1:8527 FRANKLIN COVE WAY
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46239-2261
Mailing Address - Country:US
Mailing Address - Phone:317-746-4971
Mailing Address - Fax:
Practice Address - Street 1:8527 FRANKLIN COVE WAY
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46239-2261
Practice Address - Country:US
Practice Address - Phone:317-746-4971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-16
Last Update Date:2019-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1114498136Medicaid