Basic Information
| Provider Information | |||||||||
| NPI: | 1780200105 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STURGEON | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | BA PSYCHOLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11620 AIRLINE HWY APT 214 | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708166202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2253370832 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11940 BRICKSOME AVE STE C | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708162594 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2252505829 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2020 | ||||||||
| LastUpdateDate: | 06/22/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.