Basic Information
| Provider Information | |||||||||
| NPI: | 1669764577 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENN | ||||||||
| FirstName: | SHELLEY | ||||||||
| MiddleName: | JOYCE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
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| OtherOrganizationName: | |||||||||
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| OtherLastName: | NEWMAN | ||||||||
| OtherFirstName: | SHELLEY | ||||||||
| OtherMiddleName: | JOYCE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9465 FARNHAM | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585732600 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 545 N MOLLISON | ||||||||
| Address2: | |||||||||
| City: | EL CAJON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195790947 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2011 | ||||||||
| LastUpdateDate: | 06/19/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 106H00000X | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.