Provider Demographics
NPI:1295230423
Name:BENN, MARY KESEWAA (LMSW, CASAC-T)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KESEWAA
Last Name:BENN
Suffix:
Gender:F
Credentials:LMSW, CASAC-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9705 HORACE HARDING EXPY APT 16K
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368-4106
Mailing Address - Country:US
Mailing Address - Phone:646-610-2134
Mailing Address - Fax:
Practice Address - Street 1:10819 ROCKAWAY BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11420-1034
Practice Address - Country:US
Practice Address - Phone:718-845-2620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-29
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101496-11041C0700X
NY32362101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)