Healthcare Provider Details

I. General information

NPI: 1295320083
Provider Name (Legal Business Name): LLC OF REGINA BENNER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2021
Last Update Date: 03/04/2021
Certification Date: 03/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

672A KNOWLES AVE
SOUTHAMPTON PA
18966-4102
US

IV. Provider business mailing address

109 SUMMIT AVE
WILLOW GROVE PA
19090-3108
US

V. Phone/Fax

Practice location:
  • Phone: 215-407-5232
  • Fax:
Mailing address:
  • Phone: 121-540-7523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MRS. REGINA C BENNER
Title or Position: OUTPATIENT THERAPIST
Credential: MSW, LCSW, RPT
Phone: 215-407-5232