Provider Demographics
NPI:1326869108
Name:BENAVIDES, ILENE
Entity type:Individual
Prefix:
First Name:ILENE
Middle Name:
Last Name:BENAVIDES
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 1:12371 S KIRKWOOD RD
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:TX
Mailing Address - Zip Code:77477-9989
Mailing Address - Country:US
Mailing Address - Phone:713-955-9292
Mailing Address - Fax:
Practice Address - Street 1:4818 E SAM HOUSTON PKWY N
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77015
Practice Address - Country:US
Practice Address - Phone:713-773-5110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-23
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX218525224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant