Healthcare Provider Details

I. General information

NPI: 1083984710
Provider Name (Legal Business Name): MRS. SHALLYMAR BENDER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2012
Last Update Date: 10/13/2023
Certification Date: 10/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5201 GREAT AMERICA PKWY STE 320
SANTA CLARA CA
95054-1140
US

IV. Provider business mailing address

PO BOX 2293
FONTANA CA
92334-2293
US

V. Phone/Fax

Practice location:
  • Phone: 909-471-1490
  • Fax:
Mailing address:
  • Phone: 909-471-1490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMSW89353
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: