Provider Demographics
NPI:1225761042
Name:BENAVIDES SOLE, MARISA ISABEL
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:ISABEL
Last Name:BENAVIDES SOLE
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 1:1538 N MARTEL AVE APT 216
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90046-8610
Mailing Address - Country:US
Mailing Address - Phone:916-613-8379
Mailing Address - Fax:
Practice Address - Street 1:3782 W MARTIN LUTHER KING JR BLVD STE 330
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90008-1703
Practice Address - Country:US
Practice Address - Phone:800-954-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-08
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY35445103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist