1265948400 NPI number — MRS. REBECCA ANN BENJAMIN LMSW

Table of content: MRS. REBECCA ANN BENJAMIN LMSW (NPI 1265948400)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265948400 NPI number — MRS. REBECCA ANN BENJAMIN LMSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BENJAMIN
Provider First Name:
REBECCA
Provider Middle Name:
ANN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LMSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CONNER
Provider Other First Name:
REBECCA
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1265948400
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/15/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4511 GARFIELD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COOPERSVILLE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49404-9659
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-402-3669
Provider Business Mailing Address Fax Number:
616-954-1520

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2100 RAYBROOK ST SE STE 203
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49546-5783
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-954-1555
Provider Business Practice Location Address Fax Number:
616-954-1520
Provider Enumeration Date:
12/26/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  6801093892 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com