Provider Demographics
NPI:1629160924
Name:BENSON, STEPHEN EDWARD (PHD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:EDWARD
Last Name:BENSON
Suffix:
Gender:M
Credentials:PHD
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 1257
Mailing Address - Street 2:
Mailing Address - City:BLUE HILL
Mailing Address - State:ME
Mailing Address - Zip Code:04614-1257
Mailing Address - Country:US
Mailing Address - Phone:207-374-2357
Mailing Address - Fax:207-374-2357
Practice Address - Street 1:6 MINES ROAD
Practice Address - Street 2:
Practice Address - City:BLUE HILL
Practice Address - State:ME
Practice Address - Zip Code:04614-1257
Practice Address - Country:US
Practice Address - Phone:207-374-2357
Practice Address - Fax:207-374-2357
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS909103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM9093Medicare ID - Type Unspecified