Provider Demographics
NPI:1205289311
Name:BENAVIDES, MATTHEW MARCO
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:MARCO
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 1:1909 SEAGULL LN
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78572-4884
Mailing Address - Country:US
Mailing Address - Phone:956-827-1148
Mailing Address - Fax:
Practice Address - Street 1:201 E EXPRESSWAY 83
Practice Address - Street 2:
Practice Address - City:LA JOYA
Practice Address - State:TX
Practice Address - Zip Code:78560-4001
Practice Address - Country:US
Practice Address - Phone:956-323-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-14
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111983235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist