Provider Demographics
NPI:1780738518
Name:BENOIT, BEVERLY VISTARA (MFT)
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:VISTARA
Last Name:BENOIT
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:BEVERLY
Other - Middle Name:
Other - Last Name:BENOIT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MFT
Mailing Address - Street 1:175 CONCOURSE BLVD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-8217
Mailing Address - Country:US
Mailing Address - Phone:707-284-9237
Mailing Address - Fax:707-284-9254
Practice Address - Street 1:175 CONCOURSE BLVD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-8217
Practice Address - Country:US
Practice Address - Phone:707-284-9237
Practice Address - Fax:707-284-9254
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC30928106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFC30928OtherLICENSE #