Healthcare Provider Details

I. General information

NPI: 1043483167
Provider Name (Legal Business Name): CANDACE VIRGINIA BENTON MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2008
Last Update Date: 04/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1480 TERRACITA DR
SAN BERNARDINO CA
92404-1568
US

IV. Provider business mailing address

526 S SAN PEDRO ST
LOS ANGELES CA
90013-2102
US

V. Phone/Fax

Practice location:
  • Phone: 310-743-5035
  • Fax:
Mailing address:
  • Phone: 310-743-5035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: