Healthcare Provider Details

I. General information

NPI: 1003273558
Provider Name (Legal Business Name): CELINA CONCEPCION BENAVIDES LPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2016
Last Update Date: 09/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14677 MERRILL AVE
FONTANA CA
92335
US

IV. Provider business mailing address

233 W. BASELINE RD BOX 400
LA VERNE CA
91750
US

V. Phone/Fax

Practice location:
  • Phone: 951-643-2340
  • Fax:
Mailing address:
  • Phone: 909-833-2986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License NumberPT36261
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: