Provider Demographics
NPI:1255849154
Name:BENTMAN, MARA
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:
Last Name:BENTMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:459 BROADWAY # CRLS-R
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-4125
Mailing Address - Country:US
Mailing Address - Phone:617-349-4474
Mailing Address - Fax:617-349-6668
Practice Address - Street 1:459 BROADWAY # CRLS-R
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-4125
Practice Address - Country:US
Practice Address - Phone:617-349-4474
Practice Address - Fax:617-349-6668
Is Sole Proprietor?:No
Enumeration Date:2018-01-14
Last Update Date:2018-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1055101041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool