Provider Demographics
NPI:1871628271
Name:LORNA L. BENBENISTY, PH.D., LLC
Entity type:Organization
Organization Name:LORNA L. BENBENISTY, PH.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:LORNA
Authorized Official - Middle Name:L
Authorized Official - Last Name:BENBENISTY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:678-935-9567
Mailing Address - Street 1:10475 MEDLOCK BRIDGE RD
Mailing Address - Street 2:SUITE 315
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-2002
Mailing Address - Country:US
Mailing Address - Phone:678-935-9567
Mailing Address - Fax:678-935-9568
Practice Address - Street 1:10475 MEDLOCK BRIDGE RD
Practice Address - Street 2:SUITE 315
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-2002
Practice Address - Country:US
Practice Address - Phone:678-935-9567
Practice Address - Fax:678-935-9568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0001483103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1326108820OtherLORNA L BENBENISTY, PH.D.
GA00459797AMedicaid