Provider Demographics
NPI:1366929549
Name:BENAVIDES, ANGELA MARIE
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:MARIE
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 1:4824 E 53RD ST APT 408
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55417-5004
Mailing Address - Country:US
Mailing Address - Phone:716-870-7040
Mailing Address - Fax:
Practice Address - Street 1:601 US-6
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52246
Practice Address - Country:US
Practice Address - Phone:319-338-0581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-20
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022609-1103TR0400X, 103TC0700X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy