Provider Demographics
NPI:1588179089
Name:GILMORE, BENJAMIN ARON NICOLAS
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:ARON NICOLAS
Last Name:GILMORE
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 1:104 MALTON RD
Mailing Address - Street 2:
Mailing Address - City:NEGAUNEE
Mailing Address - State:MI
Mailing Address - Zip Code:49866-2000
Mailing Address - Country:US
Mailing Address - Phone:906-228-4692
Mailing Address - Fax:906-228-2830
Practice Address - Street 1:104 MALTON RD
Practice Address - Street 2:
Practice Address - City:NEGAUNEE
Practice Address - State:MI
Practice Address - Zip Code:49866-2000
Practice Address - Country:US
Practice Address - Phone:906-228-4692
Practice Address - Fax:906-228-2830
Is Sole Proprietor?:No
Enumeration Date:2017-12-06
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)