=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699205963
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BENJAMIN JOHN NEELEY PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2017
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1901 MAIN ST
-----------------------------------------------------
City | WASHOUGAL
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98671-4116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-583-4900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1901 MAIN ST
-----------------------------------------------------
City | WASHOUGAL
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98671-4116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-583-4900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | LH60779551
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC1900X
-----------------------------------------------------
Taxonomy Name | Counseling Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PY60779123
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------