Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103G00000X | Clinical Psychologist | 022609-1 | NY |
Y | 103TC0700X | Clinical Psychologist | 022609-1 | NY |
N | 103TP2701X | Group Psychotherapist | 022609-1 | NY |
N | 103TR0400X | Rehabilitation Psychologist | 022609-1 | NY |
NPI | 1366929549 |
---|---|
Provider Name | Angela Marie Benavides |
First Address | Minneapolis, MN 55417-5004 |
Second Address | Iowa City, IA 52246 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/07/2018 |
Last Update Date | 20/07/2018 |