Provider Demographics
NPI:1649772872
Name:BENASULY, KERYN JOHNSON (LCSW)
Entity type:Individual
Prefix:MS
First Name:KERYN
Middle Name:JOHNSON
Last Name:BENASULY
Suffix:
Gender:F
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:BRIDGEWAY HOSPICE
Mailing Address - Street 2:2000 RIVERSIDE PKWY SUITE 107
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043
Mailing Address - Country:US
Mailing Address - Phone:678-878-3215
Mailing Address - Fax:678-878-3341
Practice Address - Street 1:2000 RIVERSIDE PKWY STE 107
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-5926
Practice Address - Country:US
Practice Address - Phone:678-878-3215
Practice Address - Fax:678-878-3341
Is Sole Proprietor?:No
Enumeration Date:2018-03-04
Last Update Date:2018-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0063201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical