Healthcare Provider Details

I. General information

NPI: 1164094587
Provider Name (Legal Business Name): MARISLEY BENITEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARISLEY BENITEZ CBHCM

II. Dates (important events)

Enumeration Date: 07/14/2021
Last Update Date: 07/14/2021
Certification Date: 07/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9900 STIRLING RD STE 103
HOLLYWOOD FL
33024-8073
US

IV. Provider business mailing address

9900 STIRLING RD STE 103
HOLLYWOOD FL
33024-8073
US

V. Phone/Fax

Practice location:
  • Phone: 954-300-2921
  • Fax: 954-901-2815
Mailing address:
  • Phone: 954-300-2921
  • Fax: 954-901-2815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberCBHCM103539
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: