Basic Information
| Provider Information | |||||||||
| NPI: | 1861028706 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENAVIDES | ||||||||
| FirstName: | PHILLIP | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4208 STONE TRAIL DR | ||||||||
| Address2: | |||||||||
| City: | DENTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762101517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146213065 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2225 PARKER RD | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750104711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722424114 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2020 | ||||||||
| LastUpdateDate: | 03/22/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 77347 | TX | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 77347 | TX | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 77347 | TX | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101Y00000X | 77347 | TX | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.