Provider Demographics
NPI:1326108820
Name:BENBENISTY, LORNA L (PHD)
Entity Type:Individual
Prefix:DR
First Name:LORNA
Middle Name:L
Last Name:BENBENISTY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10475 MEDLOCK BRIDGE RD
Mailing Address - Street 2:315
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30097-4433
Mailing Address - Country:US
Mailing Address - Phone:678-935-9567
Mailing Address - Fax:678-935-9568
Practice Address - Street 1:10475 MEDLOCK BRIDGE RD
Practice Address - Street 2:SUITE 315
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-4433
Practice Address - Country:US
Practice Address - Phone:678-935-9567
Practice Address - Fax:678-935-9568
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0001483103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00459797AMedicaid