Healthcare Provider Details

I. General information

NPI: 1386226330
Provider Name (Legal Business Name): NANCY BENNETT LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2021
Last Update Date: 04/28/2021
Certification Date: 04/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 POPLAR DR
PETERSBURG VA
23805-9367
US

IV. Provider business mailing address

4887 OLD MANSION RD
LUNENBURG VA
23952-2107
US

V. Phone/Fax

Practice location:
  • Phone: 804-733-6874
  • Fax:
Mailing address:
  • Phone: 434-264-2610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0701010457
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: