1982937207 NPI number — MS. ANNETTA SERENA BENJAMIN LPC

Table of content: MS. ANNETTA SERENA BENJAMIN LPC (NPI 1982937207)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982937207 NPI number — MS. ANNETTA SERENA BENJAMIN LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BENJAMIN
Provider First Name:
ANNETTA
Provider Middle Name:
SERENA
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1982937207
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/18/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8140 ASHTON AVE
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
MANASSAS
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20109-5698
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-330-9933
Provider Business Mailing Address Fax Number:
703-368-8454

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12721 DARBY BROOK CT
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
WOODBRIDGE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22192-2408
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-497-1771
Provider Business Practice Location Address Fax Number:
703-497-1225
Provider Enumeration Date:
09/18/2009

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: 101YM0800X , with the licence number:  0701004674 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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