Basic Information
| Provider Information | |||||||||
| NPI: | 1932791902 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENJAMIN | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | ELENA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17736 HATTERAS ST APT 25 | ||||||||
| Address2: | |||||||||
| City: | ENCINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913161132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103923070 | ||||||||
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| Practice Location | |||||||||
| Address1: | 503 OCEAN FRONT WALK | ||||||||
| Address2: | |||||||||
| City: | VENICE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902912403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103923070 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2021 | ||||||||
| LastUpdateDate: | 02/10/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 1497809735 | 05 | CA | MEDICAID |