Healthcare Provider Details

I. General information

NPI: 1982937207
Provider Name (Legal Business Name): ANNETTA SERENA BENJAMIN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2009
Last Update Date: 09/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12721 DARBY BROOK CT SUITE 102
WOODBRIDGE VA
22192-2408
US

IV. Provider business mailing address

8140 ASHTON AVE SUITE 200
MANASSAS VA
20109-5698
US

V. Phone/Fax

Practice location:
  • Phone: 703-497-1771
  • Fax: 703-497-1225
Mailing address:
  • Phone: 703-330-9933
  • Fax: 703-368-8454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0701004674
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: