Provider Demographics
NPI:1285332197
Name:BENEJAM, GUSTAVO ALBERTO (PSYD)
Entity type:Individual
Prefix:DR
First Name:GUSTAVO
Middle Name:ALBERTO
Last Name:BENEJAM
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 NE 16TH ST APT 6
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-4812
Mailing Address - Country:US
Mailing Address - Phone:561-350-7761
Mailing Address - Fax:
Practice Address - Street 1:2730 SW 3RD AVE STE 305
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33129-2323
Practice Address - Country:US
Practice Address - Phone:561-350-7761
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-20
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY11658103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist