Provider Demographics
NPI:1063645364
Name:BENTON, STEFAN (MFT)
Entity Type:Individual
Prefix:MR
First Name:STEFAN
Middle Name:
Last Name:BENTON
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 TAMAL VISTA BLVD
Mailing Address - Street 2:SUITE 224
Mailing Address - City:CORTE MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:94925-1130
Mailing Address - Country:US
Mailing Address - Phone:415-924-7785
Mailing Address - Fax:415-924-7785
Practice Address - Street 1:21 TAMAL VISTA BLVD
Practice Address - Street 2:SUITE 224
Practice Address - City:CORTE MADERA
Practice Address - State:CA
Practice Address - Zip Code:94925-1130
Practice Address - Country:US
Practice Address - Phone:415-924-7785
Practice Address - Fax:415-924-7785
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-02
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC34786106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist