Provider Demographics
NPI:1992210900
Name:ADDISON, BENJAMIN (LCSW)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:ADDISON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3439 DUNN ST SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-7928
Mailing Address - Country:US
Mailing Address - Phone:404-583-7994
Mailing Address - Fax:
Practice Address - Street 1:3439 DUNN ST SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-7928
Practice Address - Country:US
Practice Address - Phone:404-583-7994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-13
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0061611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical