Provider Demographics
NPI:1932559556
Name:BENOLOGA, CODI JO (LSCSW)
Entity Type:Individual
Prefix:MRS
First Name:CODI
Middle Name:JO
Last Name:BENOLOGA
Suffix:
Gender:F
Credentials:LSCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1329 18TH ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:KS
Mailing Address - Zip Code:66935-2209
Mailing Address - Country:US
Mailing Address - Phone:785-527-8271
Mailing Address - Fax:785-527-8317
Practice Address - Street 1:1115 WESTPORT DR STE D2
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66502-2880
Practice Address - Country:US
Practice Address - Phone:785-560-3101
Practice Address - Fax:785-527-8317
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-14
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS50741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201153590AMedicaid