Basic Information
| Provider Information | |||||||||
| NPI: | 1548990591 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENITO | ||||||||
| FirstName: | SHANDRA | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6140 S BROADWAY | ||||||||
| Address2: | |||||||||
| City: | LORAIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440533891 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402044315 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6140 S BROADWAY | ||||||||
| Address2: | |||||||||
| City: | LORAIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440533891 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402337232 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2022 | ||||||||
| LastUpdateDate: | 06/13/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | S.2207532 | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.