Provider Demographics
NPI:1508600263
Name:BENITEZ, TOMAS III
Entity type:Individual
Prefix:
First Name:TOMAS
Middle Name:
Last Name:BENITEZ
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1810 G AVE APT 5
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-2848
Mailing Address - Country:US
Mailing Address - Phone:541-786-3361
Mailing Address - Fax:
Practice Address - Street 1:105 FIR ST STE 327
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-2663
Practice Address - Country:US
Practice Address - Phone:541-786-3361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-19
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT243637101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)