Basic Information
| Provider Information | |||||||||
| NPI: | 1891308235 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENITEZ | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ORNELAS | ||||||||
| OtherFirstName: | LESLIE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7500 SAN FELIPE ST STE 990 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770631708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2818263382 | ||||||||
| FaxNumber: | 8326532491 | ||||||||
| Practice Location | |||||||||
| Address1: | 6824 LOGUE LN | ||||||||
| Address2: | |||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 767087241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2543272001 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2020 | ||||||||
| LastUpdateDate: | 02/10/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-22-57710 | TX | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.