Healthcare Provider Details

I. General information

NPI: 1174257802
Provider Name (Legal Business Name): BENITA NA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2022
Last Update Date: 07/09/2022
Certification Date: 07/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1932 14TH ST
SANTA MONICA CA
90404-4605
US

IV. Provider business mailing address

4915 SAWTELLE BLVD APT 6
CULVER CITY CA
90230-4851
US

V. Phone/Fax

Practice location:
  • Phone: 310-344-2276
  • Fax:
Mailing address:
  • Phone: 562-489-6019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: