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General NPI Number Information
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NPI Number | 1144910746
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Entity Type | Organization
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Legal Business Name | BENNETT GROUP HOME LLC
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Dates
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Enumeration Date | 05/09/2023
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Last Update Date | 05/09/2023
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Provider Practice Location Address
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Address Line | 16020 CROSSED TALONS RD
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City | WOODBRIDGE
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State | VA
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Zip | 22193-5797
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Country | US
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Telephone | 703-597-6529
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Fax |
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Provider Business Mailing Address
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Address Line | 16020 CROSSED TALONS RD
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City | WOODBRIDGE
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State | VA
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Zip | 22193-5797
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Country | US
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Telephone | 703-597-6529
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | DR. ABENA FYNN SWATSON
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Credential | BS, MBA, PHD
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Telephone | 703-597-6529
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number |
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License Number State |
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