Provider Demographics
NPI:1972181980
Name:BENNAFIELD, TEDRA
Entity Type:Individual
Prefix:
First Name:TEDRA
Middle Name:
Last Name:BENNAFIELD
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 1:1130 WILLOW GREEN DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23602-7114
Mailing Address - Country:US
Mailing Address - Phone:757-343-0523
Mailing Address - Fax:
Practice Address - Street 1:3630 GEORGE WASHINGTON MEM HWY STE D
Practice Address - Street 2:
Practice Address - City:YORKTOWN
Practice Address - State:VA
Practice Address - Zip Code:23693-3350
Practice Address - Country:US
Practice Address - Phone:757-690-9508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-31
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician