Provider Demographics
NPI:1568207496
Name:BENTON, MARANDA MARIE
Entity type:Individual
Prefix:
First Name:MARANDA
Middle Name:MARIE
Last Name:BENTON
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 1:18160 ALDER ST
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-5042
Mailing Address - Country:US
Mailing Address - Phone:760-486-7586
Mailing Address - Fax:
Practice Address - Street 1:612 S MYRTLE AVE STE 100
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016-3406
Practice Address - Country:US
Practice Address - Phone:626-472-8722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician