=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669187019
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KI-JANA BENAIN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/19/2023
-----------------------------------------------------
Last Update Date | 01/19/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12333 83RD AVE APT 2705
-----------------------------------------------------
City | KEW GARDENS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11415-3471
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-229-4618
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12333 83RD AVE
-----------------------------------------------------
City | KEW GARDENS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11415-3421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 117744
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------