Healthcare Provider Details

I. General information

NPI: 1831894153
Provider Name (Legal Business Name): BENETTA GREENE NEALY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2023
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1149 W 190TH ST STE 2200
GARDENA CA
90248-4344
US

IV. Provider business mailing address

1149 W 190TH ST STE 2200
GARDENA CA
90248-4344
US

V. Phone/Fax

Practice location:
  • Phone: 310-856-0800
  • Fax: 310-856-0800
Mailing address:
  • Phone: 310-856-0800
  • Fax: 855-568-2494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: