Provider Demographics
NPI:1124087051
Name:BENAVIDES, MARY ANN (PH D)
Entity type:Individual
Prefix:DR
First Name:MARY ANN
Middle Name:
Last Name:BENAVIDES
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:DR
Other - First Name:MARY ANN
Other - Middle Name:F
Other - Last Name:BENAVIDES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:7425 MAPLE TERRACE
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-3154
Mailing Address - Country:US
Mailing Address - Phone:414-475-5815
Mailing Address - Fax:
Practice Address - Street 1:7425 MAPLE TERRACE
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213-3154
Practice Address - Country:US
Practice Address - Phone:414-475-5815
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1319057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39081700Medicaid