Provider Demographics
NPI:1316600869
Name:BENSON, BRENDOLYNNE
Entity Type:Individual
Prefix:
First Name:BRENDOLYNNE
Middle Name:
Last Name:BENSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11110 BOARDWALK DR APT 11
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-8393
Mailing Address - Country:US
Mailing Address - Phone:225-235-6848
Mailing Address - Fax:
Practice Address - Street 1:11110 BOARDWALK DR APT 11
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-8393
Practice Address - Country:US
Practice Address - Phone:225-235-6848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-20
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA00000Medicaid