Provider Demographics
NPI:1710335849
Name:BENNETT, BRANDY NICKOLE (LBA)
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:NICKOLE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:174 COSTELLO DR
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22602-4306
Mailing Address - Country:US
Mailing Address - Phone:540-662-7007
Mailing Address - Fax:540-662-1311
Practice Address - Street 1:174 COSTELLO DR
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22602-4306
Practice Address - Country:US
Practice Address - Phone:540-662-7007
Practice Address - Fax:540-662-1311
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-31
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133000762103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst