Healthcare Provider Details

I. General information

NPI: 1912692609
Provider Name (Legal Business Name): LAURA DINE MBENG LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2023
Last Update Date: 12/12/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4545 42ND ST NW STE 105
WASHINGTON DC
20016-4623
US

IV. Provider business mailing address

4530 WISCONSIN AVE NW
WASHINGTON DC
20016-4627
US

V. Phone/Fax

Practice location:
  • Phone: 571-236-4880
  • Fax:
Mailing address:
  • Phone: 202-536-4414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPRC200002191
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: