Provider Demographics
NPI:1083370621
Name:BENINGA, KELLY JACOB (MA, CHT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JACOB
Last Name:BENINGA
Suffix:
Gender:M
Credentials:MA, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7220 W JEFFERSON AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80235-2023
Mailing Address - Country:US
Mailing Address - Phone:303-903-5523
Mailing Address - Fax:
Practice Address - Street 1:7220 W JEFFERSON AVE STE 210
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80235-2023
Practice Address - Country:US
Practice Address - Phone:303-903-5523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-09
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CONLC.0110096101YM0800X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health