Provider Demographics
NPI:1013028604
Name:DIBENEDETTO, CAMILLE M (PSYD)
Entity Type:Individual
Prefix:DR
First Name:CAMILLE
Middle Name:M
Last Name:DIBENEDETTO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 391288
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139
Mailing Address - Country:US
Mailing Address - Phone:617-492-8775
Mailing Address - Fax:617-924-1027
Practice Address - Street 1:49 HANCOCK ST
Practice Address - Street 2:SUITE 205
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139
Practice Address - Country:US
Practice Address - Phone:617-492-8775
Practice Address - Fax:617-924-1027
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6087103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW04866Medicare ID - Type Unspecified