Provider Demographics
NPI:1346574860
Name:BENAVIDEZ, PEGGY (LCSW)
Entity type:Individual
Prefix:
First Name:PEGGY
Middle Name:
Last Name:BENAVIDEZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4112 OUTLOOK BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-1667
Mailing Address - Country:US
Mailing Address - Phone:719-553-1073
Mailing Address - Fax:719-553-1107
Practice Address - Street 1:4112 OUTLOOK BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-1667
Practice Address - Country:US
Practice Address - Phone:719-553-1073
Practice Address - Fax:719-553-1107
Is Sole Proprietor?:No
Enumeration Date:2009-09-30
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO938OtherLICENSED CLINICAL SOCIAL WORKER