MEDICARE: DEBRA MARIE BENEVIDEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	167G00000X	Licensed Psychiatric Technician	PT 36200	CA

General Provider Information

NPI Number	:	1225464308
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEBRA MARIE BENEVIDEZ

Provider Business Mailing Address
First Line	:	2811 COLD SPRINGS RD
Second Line	:
City	:	PLACERVILLE
State	:	CA
Zip	:	95667-4044
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2811 COLD SPRINGS RD
Second Line	:
City	:	PLACERVILLE
State	:	CA
Zip	:	95667-4044
Country	:	US
Telephone Number	:	530-621-6213
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/19/2013
Last Update Date	:	09/19/2013

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Directions to “ DEBRA MARIE BENEVIDEZ ” Practice Location

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