MEDICARE: MS. SHAQUAWNNA LATOYA BENJAMIN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number State
1	101YM0800X	Mental Health Counselor
2	106S00000X	Behavior Technician
3	251B00000X	Case Management Agency
4	251S00000X	Community/Behavioral Health Agency
5	253Z00000X	In Home Supportive Care Agency
6	3747P1801X	Personal Care Attendant
7	376J00000X	Homemaker
8	251E00000X	Home Health Agency	FL

General Provider Information

NPI Number	:	1174191993
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SHAQUAWNNA LATOYA BENJAMIN

Provider Business Mailing Address
First Line	:	4702 S WASHINGTON AVE
Second Line	:
City	:	TITUSVILLE
State	:	FL
Zip	:	32780-7305
Country	:	US
Telephone Number	:	407-675-1547
Fax Number	:

Provider Business Practice Location Address
First Line	:	4702 S WASHINGTON AVE
Second Line	:
City	:	TITUSVILLE
State	:	FL
Zip	:	32780-7305
Country	:	US
Telephone Number	:	407-675-1547
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2021
Last Update Date	:	06/17/2021

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