Provider Demographics
NPI:1063198174
Name:BENCIVENGA, PAYTON
Entity type:Individual
Prefix:
First Name:PAYTON
Middle Name:
Last Name:BENCIVENGA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 UNIONVILLE INDIAN TRAIL RD W STE B202
Mailing Address - Street 2:
Mailing Address - City:INDIAN TRAIL
Mailing Address - State:NC
Mailing Address - Zip Code:28079-5670
Mailing Address - Country:US
Mailing Address - Phone:704-234-8003
Mailing Address - Fax:
Practice Address - Street 1:120 UNIONVILLE INDIAN TRAIL RD W STE B202
Practice Address - Street 2:
Practice Address - City:INDIAN TRAIL
Practice Address - State:NC
Practice Address - Zip Code:28079-5670
Practice Address - Country:US
Practice Address - Phone:704-234-8003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-23
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA18880101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health