Basic Information
Provider Information | |||||||||
NPI: | 1134290174 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BENAWAY | ||||||||
FirstName: | SANDRA | ||||||||
MiddleName: | L. | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MA, LLP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1 HURLEY PLZ | ||||||||
Address2: | 5TH FLOOR S.O.N. | ||||||||
City: | FLINT | ||||||||
State: | MI | ||||||||
PostalCode: | 485035902 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8107627038 | ||||||||
FaxNumber: | 8107600440 | ||||||||
Practice Location | |||||||||
Address1: | 1085 S LINDEN RD STE 150 | ||||||||
Address2: |   | ||||||||
City: | FLINT | ||||||||
State: | MI | ||||||||
PostalCode: | 485323430 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8102622100 | ||||||||
FaxNumber: | 8102303376 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/13/2006 | ||||||||
LastUpdateDate: | 04/12/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/12/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 6301002856 | MI | Y |   | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
ID | Type | State | Issuer | Description | 750910736 | 01 | MI | BLUE SHIELD | OTHER |