Provider Demographics
NPI:1093182594
Name:EJINDU, BENEDICTA N (MED)
Entity Type:Individual
Prefix:MRS
First Name:BENEDICTA
Middle Name:N
Last Name:EJINDU
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5125 WELLS DR
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-7057
Mailing Address - Country:US
Mailing Address - Phone:912-541-2801
Mailing Address - Fax:
Practice Address - Street 1:5125 WELLS DR
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-7057
Practice Address - Country:US
Practice Address - Phone:912-541-2801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-01
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC008443101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GALPC008443OtherGA LICENSE