Provider Demographics
NPI:1295024578
Name:BENVENUTO, MICHAEL (BCBA)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:BENVENUTO
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 INTERNATIONAL PKWY
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-5035
Mailing Address - Country:US
Mailing Address - Phone:561-260-5900
Mailing Address - Fax:
Practice Address - Street 1:166 PROFESSIONAL WAY
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-6391
Practice Address - Country:US
Practice Address - Phone:561-260-5900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-07
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-05-2131103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst