Provider Demographics
NPI:1558630491
Name:POLING, BENJAMIN (MA)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:POLING
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17150 UNIVERSITY AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SANDY
Mailing Address - State:OR
Mailing Address - Zip Code:97055-9290
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17150 UNIVERSITY AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:SANDY
Practice Address - State:OR
Practice Address - Zip Code:97055-9290
Practice Address - Country:US
Practice Address - Phone:503-668-5001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-21
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor