=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043619596
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELBA CAROLINA BENITEZ PHD, LPC, NCC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2014
-----------------------------------------------------
Last Update Date | 05/13/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6050 HICKORY GROVE RD
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28215-4130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-426-9724
-----------------------------------------------------
Fax | 704-531-4068
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7200 E WT HARRIS BLVD
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28215-7200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-426-9724
-----------------------------------------------------
Fax | 704-531-4068
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | A10962
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------