Provider Demographics
NPI:1073322624
Name:BENAVIDEZ, ODESSA
Entity type:Individual
Prefix:
First Name:ODESSA
Middle Name:
Last Name:BENAVIDEZ
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 1:423 WOODLARK ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93535-4017
Mailing Address - Country:US
Mailing Address - Phone:661-547-2927
Mailing Address - Fax:
Practice Address - Street 1:44447 10TH ST W
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-3324
Practice Address - Country:US
Practice Address - Phone:661-726-2630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-07
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMPSS-OTPYNB175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist