=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417618968
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BENJAMIN THOMAS HERMAN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/06/2022
-----------------------------------------------------
Last Update Date | 01/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 28600 GRAYS SHOP RD
-----------------------------------------------------
City | NEWSOMS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23874-2904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-654-6461
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5528 CABIN JOHN DR
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23464-9011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-619-5275
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 0119009277
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------