Healthcare Provider Details

I. General information

NPI: 1770182628
Provider Name (Legal Business Name): KEVIN JORGE BENITEZ AMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2020
Last Update Date: 10/21/2020
Certification Date: 10/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15740 TURNBERRY ST
MORENO VALLEY CA
92555-4903
US

IV. Provider business mailing address

25384 PARK AVE
LOMA LINDA CA
92354-2323
US

V. Phone/Fax

Practice location:
  • Phone: 951-363-8449
  • Fax:
Mailing address:
  • Phone: 909-705-2761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number120390
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: