Provider Demographics
NPI:1639635360
Name:BENIDT, CAMERON D
Entity Type:Individual
Prefix:
First Name:CAMERON
Middle Name:D
Last Name:BENIDT
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 1:11 WINGS FALLS CT
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-9137
Mailing Address - Country:US
Mailing Address - Phone:518-788-7083
Mailing Address - Fax:
Practice Address - Street 1:220 BROADWAY
Practice Address - Street 2:
Practice Address - City:FORT EDWARD
Practice Address - State:NY
Practice Address - Zip Code:12828-1502
Practice Address - Country:US
Practice Address - Phone:518-338-3482
Practice Address - Fax:518-334-3484
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-19
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001473103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty