Provider Demographics
NPI:1912529066
Name:BENHAM, STACY ILENE (LCSW)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:ILENE
Last Name:BENHAM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 S GRAND CANYON DR APT 2003
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-3671
Mailing Address - Country:US
Mailing Address - Phone:626-684-6349
Mailing Address - Fax:
Practice Address - Street 1:2601 S GRAND CANYON DR APT 2003
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-3671
Practice Address - Country:US
Practice Address - Phone:626-684-6349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-12
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV8186-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty