Provider Demographics
NPI:1023616869
Name:GILBERT, BENNECIA (CRC, NCC, LPC)
Entity type:Individual
Prefix:
First Name:BENNECIA
Middle Name:
Last Name:GILBERT
Suffix:
Gender:F
Credentials:CRC, NCC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6001 TRAMMELL RD APT 111
Mailing Address - Street 2:
Mailing Address - City:MORROW
Mailing Address - State:GA
Mailing Address - Zip Code:30260-1351
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:139 HENRY PKWY
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-6636
Practice Address - Country:US
Practice Address - Phone:770-358-5252
Practice Address - Fax:770-898-7412
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-14
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC0117782255A2300X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer