Provider Demographics
NPI:1275303596
Name:VAN BENEDEN, DOMINICK WILLIAM
Entity Type:Individual
Prefix:
First Name:DOMINICK
Middle Name:WILLIAM
Last Name:VAN BENEDEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2521 N ELMS RD
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:MI
Mailing Address - Zip Code:48433-9423
Mailing Address - Country:US
Mailing Address - Phone:866-498-3909
Mailing Address - Fax:
Practice Address - Street 1:1159 S CARNEY DR
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR
Practice Address - State:MI
Practice Address - Zip Code:48079-5569
Practice Address - Country:US
Practice Address - Phone:810-328-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician