Provider Demographics
NPI:1821301185
Name:BENITEZ, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BENITEZ
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 1:12501 IMPERIAL HWY # 500B
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CA
Mailing Address - Zip Code:90650-3179
Mailing Address - Country:US
Mailing Address - Phone:562-864-7821
Mailing Address - Fax:562-864-7864
Practice Address - Street 1:12501 IMPERIAL HWY # 500B
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650-3179
Practice Address - Country:US
Practice Address - Phone:562-864-7821
Practice Address - Fax:562-864-7864
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-15
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
172V00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0287809OtherMEDI-CAL
CA02870709OtherMEDI-CAL
CA02870709Medicare PIN