Provider Demographics
NPI:1508972100
Name:VIRDEN, BENJAMIN F JR (LAC)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:F
Last Name:VIRDEN
Suffix:JR
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 KENDALL LN
Mailing Address - Street 2:
Mailing Address - City:BOYCE
Mailing Address - State:LA
Mailing Address - Zip Code:71409-9708
Mailing Address - Country:US
Mailing Address - Phone:318-793-0944
Mailing Address - Fax:
Practice Address - Street 1:401 RAINBOW DR UNIT 35
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360-6979
Practice Address - Country:US
Practice Address - Phone:318-487-5191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL.A.C. # 753101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAG9759OtherBLUECROSS BLUESHIELD
LAG9759OtherBLUECROSS BLUESHIELD