Provider Demographics
NPI:1457627812
Name:STILLMAN, BENJAMIN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:
Last Name:STILLMAN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:365 WEST RD STE 150
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER CENTER
Mailing Address - State:VT
Mailing Address - Zip Code:05255-6308
Mailing Address - Country:US
Mailing Address - Phone:802-491-7645
Mailing Address - Fax:
Practice Address - Street 1:4697 MAIN ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER CENTER
Practice Address - State:VT
Practice Address - Zip Code:05255-8916
Practice Address - Country:US
Practice Address - Phone:802-768-9136
Practice Address - Fax:802-662-2173
Is Sole Proprietor?:No
Enumeration Date:2012-03-29
Last Update Date:2022-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT048.0134146103TC0700X
GA3066103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical