MEDICARE: STACY ILENE BENHAM LCSW

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	8186-C	NV

General Provider Information

NPI Number	:	1912529066
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACY ILENE BENHAM LCSW

Provider Business Mailing Address
First Line	:	2601 S GRAND CANYON DR APT 2003
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-3671
Country	:	US
Telephone Number	:	626-684-6349
Fax Number	:

Provider Business Practice Location Address
First Line	:	2601 S GRAND CANYON DR APT 2003
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-3671
Country	:	US
Telephone Number	:	626-684-6349
Fax Number	:

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

Provider Enumeration Date	:	05/12/2020
Last Update Date	:	05/12/2020

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