Provider Demographics
NPI:1801323936
Name:BENNER, NAHRAIN COLLEEN (SUDCC- II CS 11072)
Entity type:Individual
Prefix:
First Name:NAHRAIN
Middle Name:COLLEEN
Last Name:BENNER
Suffix:
Gender:F
Credentials:SUDCC- II CS 11072
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10100 TRINITY PKWY
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-7238
Mailing Address - Country:US
Mailing Address - Phone:209-953-3700
Mailing Address - Fax:209-953-9199
Practice Address - Street 1:1904 RICHLAND AVE
Practice Address - Street 2:
Practice Address - City:CERES
Practice Address - State:CA
Practice Address - Zip Code:95307-4562
Practice Address - Country:US
Practice Address - Phone:209-541-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-19
Last Update Date:2025-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 171M00000X
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program