Healthcare Provider Details

I. General information

NPI: 1063198000
Provider Name (Legal Business Name): MARILYN JOSEPHINE BENEDICT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2023
Last Update Date: 06/26/2023
Certification Date: 06/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 QUORUM DR APT 103
ROANOKE TX
76262-5406
US

IV. Provider business mailing address

2104 GREENBRIAR DR
SOUTHLAKE TX
76092-8355
US

V. Phone/Fax

Practice location:
  • Phone: 918-896-2215
  • Fax:
Mailing address:
  • Phone: 817-442-9022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-16-16039
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: