Provider Demographics
NPI:1124860705
Name:GROSSNICKLE, BENJAMIN JARED (LCSW-A, LCAS-A)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:JARED
Last Name:GROSSNICKLE
Suffix:
Gender:M
Credentials:LCSW-A, LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2602 COURTIER DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-7818
Mailing Address - Country:US
Mailing Address - Phone:252-752-0483
Mailing Address - Fax:252-757-3172
Practice Address - Street 1:2602 COURTIER DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-7818
Practice Address - Country:US
Practice Address - Phone:252-752-0483
Practice Address - Fax:252-757-3172
Is Sole Proprietor?:No
Enumeration Date:2024-06-12
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-29816101YA0400X
NCC0179881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)