Provider Demographics
NPI:1821530551
Name:BENAVIDEZ, THERESA MARIE (BCBA, MA)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:MARIE
Last Name:BENAVIDEZ
Suffix:
Gender:F
Credentials:BCBA, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 COUNTY ROAD 11A
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:CO
Mailing Address - Zip Code:81226-9502
Mailing Address - Country:US
Mailing Address - Phone:915-249-0365
Mailing Address - Fax:
Practice Address - Street 1:310 COUNTY ROAD 11A
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:CO
Practice Address - Zip Code:81226-9502
Practice Address - Country:US
Practice Address - Phone:915-249-0365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-11
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-16-16571106S00000X
CO1-17-25819103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO46473041Medicaid