Healthcare Provider Details

I. General information

NPI: 1144751579
Provider Name (Legal Business Name): CARLOS FABRICIO BENAVIDES LCSW135470
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2017
Last Update Date: 11/14/2025
Certification Date: 11/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 E WARDLOW RD
LONG BEACH CA
90807-4628
US

IV. Provider business mailing address

850 E WARDLOW RD
LONG BEACH CA
90807-4628
US

V. Phone/Fax

Practice location:
  • Phone: 562-981-9392
  • Fax:
Mailing address:
  • Phone: 310-523-9500
  • Fax: 310-225-2725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW76018
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW112732
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW112732
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW135470
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: