Healthcare Provider Details

I. General information

NPI: 1740309525
Provider Name (Legal Business Name): DOMINIQUE BENAVIDEZ PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 06/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

335 REDONDO AVE
LONG BEACH CA
90814
US

IV. Provider business mailing address

904 SILVER SPUR RD # 297
ROLLING HILLS ESTATES CA
90274-3800
US

V. Phone/Fax

Practice location:
  • Phone: 562-434-3030
  • Fax: 562-434-3212
Mailing address:
  • Phone: 310-373-0800
  • Fax: 310-373-0868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number22620
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number22620
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number22620
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number22620
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License NumberRPS2005098
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: