Provider Demographics
NPI:1053557108
Name:BENJAMIN, NICOLE MICHELLE (LCMHC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MICHELLE
Last Name:BENJAMIN
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 14022
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27620-4022
Mailing Address - Country:US
Mailing Address - Phone:252-977-0201
Mailing Address - Fax:252-977-0204
Practice Address - Street 1:107 SE MAIN ST
Practice Address - Street 2:SUITE 208
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27801-5400
Practice Address - Country:US
Practice Address - Phone:252-977-0201
Practice Address - Fax:252-977-0204
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-19
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7215101Y00000X, 101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional