Healthcare Provider Details

I. General information

NPI: 1023720067
Provider Name (Legal Business Name): BENJAMIN HENRY BIASELLA AAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2022
Last Update Date: 12/21/2022
Certification Date: 12/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6221 NE FOURTH PLAIN BLVD APT 130
VANCOUVER WA
98661-7210
US

IV. Provider business mailing address

6221 NE FOURTH PLAIN BLVD APT 130
VANCOUVER WA
98661-7210
US

V. Phone/Fax

Practice location:
  • Phone: 360-831-0908
  • Fax:
Mailing address:
  • Phone: 360-831-0908
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: