Healthcare Provider Details

I. General information

NPI: 1083398614
Provider Name (Legal Business Name): VIOLET VIRGINIA BIENZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2023
Last Update Date: 06/14/2023
Certification Date: 06/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2010 S YOST AVE
BLOOMINGTON IN
47403-3188
US

IV. Provider business mailing address

319 E 20TH ST APT 16
BLOOMINGTON IN
47408-1565
US

V. Phone/Fax

Practice location:
  • Phone: 812-822-0605
  • Fax:
Mailing address:
  • Phone: 574-575-5704
  • Fax: 812-822-2496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-23-27-6857
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: