Provider Demographics
NPI:1770280430
Name:BENVENUTO, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BENVENUTO
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 1:12877 ROYAL BIRKDALE RD
Mailing Address - Street 2:
Mailing Address - City:PEYTON
Mailing Address - State:CO
Mailing Address - Zip Code:80831-4097
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12877 ROYAL BIRKDALE RD
Practice Address - Street 2:
Practice Address - City:PEYTON
Practice Address - State:CO
Practice Address - Zip Code:80831-4097
Practice Address - Country:US
Practice Address - Phone:619-337-4644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-13
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-23-265926106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician