Provider Demographics
NPI:1598280745
Name:MARY K. BENJAMIN, LICSW, INC
Entity Type:Organization
Organization Name:MARY K. BENJAMIN, LICSW, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:K
Authorized Official - Last Name:BENJAMIN
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:401-419-5147
Mailing Address - Street 1:49 TYLER DR
Mailing Address - Street 2:
Mailing Address - City:UXBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01569-1189
Mailing Address - Country:US
Mailing Address - Phone:401-419-5147
Mailing Address - Fax:508-377-4106
Practice Address - Street 1:291 MAIN ST STE 10
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MA
Practice Address - Zip Code:01757-2526
Practice Address - Country:US
Practice Address - Phone:401-419-5147
Practice Address - Fax:508-377-4106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-09
Last Update Date:2017-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA115406261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health