Provider Demographics
NPI:1801950472
Name:BENAVIDES, MELISSA A (PT)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:BENAVIDES
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1353 N WESTMORELAND RD
Mailing Address - Street 2:BLDG F
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75211-1655
Mailing Address - Country:US
Mailing Address - Phone:214-333-7016
Mailing Address - Fax:
Practice Address - Street 1:1353 N WESTMORELAND RD
Practice Address - Street 2:BLDG F
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75211-1655
Practice Address - Country:US
Practice Address - Phone:214-333-7016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1072478225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX063002201Medicaid