=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619480357
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CREVELING-BENEFIELD LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2017
-----------------------------------------------------
Last Update Date | 11/15/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4300 S I 10 SERVICE RD W STE 112
-----------------------------------------------------
City | METAIRIE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70001-7425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-265-7595
-----------------------------------------------------
Fax | 800-490-8511
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4300 S I 10 SERVICE RD W STE 112
-----------------------------------------------------
City | METAIRIE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70001-7425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-265-7595
-----------------------------------------------------
Fax | 800-490-8511
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. CHRISTIANE CREVELING-BENEFIELD
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 225-405-4401
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 1296
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------