Provider Demographics
NPI:1568813137
Name:BENJAMIN, BRIEN (MA)
Entity Type:Individual
Prefix:
First Name:BRIEN
Middle Name:
Last Name:BENJAMIN
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:PO BOX 790331
Mailing Address - Street 2:
Mailing Address - City:PAIA
Mailing Address - State:HI
Mailing Address - Zip Code:96779-0331
Mailing Address - Country:US
Mailing Address - Phone:303-883-5647
Mailing Address - Fax:
Practice Address - Street 1:222 LANILOA WAY
Practice Address - Street 2:
Practice Address - City:HAIKU
Practice Address - State:HI
Practice Address - Zip Code:96708-5381
Practice Address - Country:US
Practice Address - Phone:303-883-5647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-24
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CONLC0010525101YM0800X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health