Provider Demographics
NPI:1720603335
Name:VINCENT, BENETTA
Entity Type:Individual
Prefix:
First Name:BENETTA
Middle Name:
Last Name:VINCENT
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 1:3194 SE TUMBLESTONE DR
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-7966
Mailing Address - Country:US
Mailing Address - Phone:678-548-1122
Mailing Address - Fax:
Practice Address - Street 1:3194 SE TUMBLESTONE DR
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-7966
Practice Address - Country:US
Practice Address - Phone:678-548-1122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-09
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health