Provider Demographics
NPI:1770182628
Name:BENITEZ, KEVIN JORGE (AMFT)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:JORGE
Last Name:BENITEZ
Suffix:
Gender:M
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25384 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-2323
Mailing Address - Country:US
Mailing Address - Phone:909-705-2761
Mailing Address - Fax:
Practice Address - Street 1:15740 TURNBERRY ST
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-4903
Practice Address - Country:US
Practice Address - Phone:951-363-8449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA120390106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist