Provider Demographics
NPI:1174268239
Name:BENITEZ, ADYSDANIA
Entity type:Individual
Prefix:
First Name:ADYSDANIA
Middle Name:
Last Name:BENITEZ
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 1:670 SE 28TH LN
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33033-5757
Mailing Address - Country:US
Mailing Address - Phone:786-587-7619
Mailing Address - Fax:
Practice Address - Street 1:670 SE 28TH LN
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33033-5757
Practice Address - Country:US
Practice Address - Phone:786-587-7619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-03
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20-148682106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty