Provider Demographics
NPI:1891540225
Name:WILLOUGHBY, BENJILA
Entity Type:Individual
Prefix:
First Name:BENJILA
Middle Name:
Last Name:WILLOUGHBY
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 1:4924 EMMET ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68104-3656
Mailing Address - Country:US
Mailing Address - Phone:402-594-9578
Mailing Address - Fax:
Practice Address - Street 1:4924 EMMET ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68104-3656
Practice Address - Country:US
Practice Address - Phone:402-739-2386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-19
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist