Provider Demographics
NPI:1770760720
Name:BENBOW, KEVIN LEE
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:LEE
Last Name:BENBOW
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 1:202 S 1ST AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-2366
Mailing Address - Country:US
Mailing Address - Phone:928-750-1774
Mailing Address - Fax:928-783-1065
Practice Address - Street 1:202 S 1ST AVE STE 104
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-2366
Practice Address - Country:US
Practice Address - Phone:928-750-1774
Practice Address - Fax:928-783-1065
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-22
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC 13276101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZLPC13276OtherARIZONA BOARD OF BEHAVIORAL HEALTH EXAMINERS