Provider Demographics
NPI:1639767510
Name:BENEDICT, CARMEN L (MS, BCBA)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:L
Last Name:BENEDICT
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 E PONDEROSA CIR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:SD
Mailing Address - Zip Code:57005-1900
Mailing Address - Country:US
Mailing Address - Phone:810-434-5334
Mailing Address - Fax:
Practice Address - Street 1:2542 VT ROUTE
Practice Address - Street 2:
Practice Address - City:NEWPORT CENTER
Practice Address - State:VT
Practice Address - Zip Code:05857
Practice Address - Country:US
Practice Address - Phone:802-487-9421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-06
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT146.0134188103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT146.0134188OtherBCBA LISENCE