Provider Demographics
NPI:1003936931
Name:BENOIT, THYRA JACKSON (LCSW-C, LICSW)
Entity Type:Individual
Prefix:MS
First Name:THYRA
Middle Name:JACKSON
Last Name:BENOIT
Suffix:
Gender:F
Credentials:LCSW-C, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1961 MIDDLEBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20906-5822
Mailing Address - Country:US
Mailing Address - Phone:301-460-3735
Mailing Address - Fax:301-460-3735
Practice Address - Street 1:1107 SPRING ST STE A3
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-4027
Practice Address - Country:US
Practice Address - Phone:301-460-3735
Practice Address - Fax:301-460-3735
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD017371041C0700X
DCLC3001151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD491615Medicare ID - Type Unspecified