Provider Demographics
NPI:1861028706
Name:BENAVIDES, PHILLIP MICHAEL
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:MICHAEL
Last Name:BENAVIDES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4208 STONE TRAIL DR
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76210-1517
Mailing Address - Country:US
Mailing Address - Phone:214-621-3065
Mailing Address - Fax:
Practice Address - Street 1:2225 PARKER RD
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-4711
Practice Address - Country:US
Practice Address - Phone:972-242-4114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-22
Last Update Date:2020-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX77347101YA0400X, 101YM0800X, 101YP2500X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional