Provider Demographics
NPI:1013258904
Name:BENSON, JUANIKA L
Entity Type:Individual
Prefix:
First Name:JUANIKA
Middle Name:L
Last Name:BENSON
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 1:2566 E GRAND BLVD APT 307
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48211-2026
Mailing Address - Country:US
Mailing Address - Phone:313-247-4413
Mailing Address - Fax:
Practice Address - Street 1:2566 E GRAND BLVD APT 307
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48211-2026
Practice Address - Country:US
Practice Address - Phone:313-247-4413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-03
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6361003550102L00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst