Provider Demographics
NPI:1417740622
Name:BENJAMIN, STACEY DIANE
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:DIANE
Last Name:BENJAMIN
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 1:3520 BUCKBOARD WAY
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86404-3449
Mailing Address - Country:US
Mailing Address - Phone:928-208-8410
Mailing Address - Fax:
Practice Address - Street 1:450 LAKE HAVASU AVE S UNIT 202
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-4504
Practice Address - Country:US
Practice Address - Phone:928-863-7078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-28
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional