Provider Demographics
NPI:1760173132
Name:BENAVIDES, LEILANI (LMBT)
Entity Type:Individual
Prefix:MRS
First Name:LEILANI
Middle Name:
Last Name:BENAVIDES
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2315 TULLS CREEK RD
Mailing Address - Street 2:
Mailing Address - City:MOYOCK
Mailing Address - State:NC
Mailing Address - Zip Code:27958-9032
Mailing Address - Country:US
Mailing Address - Phone:252-564-8809
Mailing Address - Fax:919-648-2546
Practice Address - Street 1:2315 TULLS CREEK RD
Practice Address - Street 2:
Practice Address - City:MOYOCK
Practice Address - State:NC
Practice Address - Zip Code:27958-9032
Practice Address - Country:US
Practice Address - Phone:252-564-8809
Practice Address - Fax:919-648-2546
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-17
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019018934225700000X
NC20623225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist