Provider Demographics
NPI:1740309525
Name:BENAVIDEZ, DOMINIQUE (PHD)
Entity type:Individual
Prefix:DR
First Name:DOMINIQUE
Middle Name:
Last Name:BENAVIDEZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 SILVER SPUR RD # 297
Mailing Address - Street 2:
Mailing Address - City:ROLLING HILLS ESTATES
Mailing Address - State:CA
Mailing Address - Zip Code:90274-3800
Mailing Address - Country:US
Mailing Address - Phone:310-373-0800
Mailing Address - Fax:310-373-0868
Practice Address - Street 1:335 REDONDO AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90814
Practice Address - Country:US
Practice Address - Phone:562-434-3030
Practice Address - Fax:562-434-3212
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22620103TA0700X, 103TB0200X, 103TC0700X, 103TC2200X
CARPS2005098103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent