Provider Demographics
NPI:1578129789
Name:EHRET, BENJAMIN SUTTER
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:SUTTER
Last Name:EHRET
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 1:74 S WILLARD ST APT 5
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-3425
Mailing Address - Country:US
Mailing Address - Phone:802-917-3194
Mailing Address - Fax:
Practice Address - Street 1:21600 OXNARD ST # WOODLAND
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91367-4976
Practice Address - Country:US
Practice Address - Phone:818-345-2345
Practice Address - Fax:818-758-8015
Is Sole Proprietor?:No
Enumeration Date:2019-05-13
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT2274679A106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTFA0V888358829000OtherBLUECROSS BLUESHIELD OF VERMONT