Provider Demographics
NPI:1730316910
Name:BENTTINEN, KERISH N (LMSW)
Entity Type:Individual
Prefix:
First Name:KERISH
Middle Name:N
Last Name:BENTTINEN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:KERISH
Other - Middle Name:MARIE
Other - Last Name:GRANT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:32 COLLEGE AVE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-6100
Mailing Address - Country:US
Mailing Address - Phone:207-680-2065
Mailing Address - Fax:207-680-2068
Practice Address - Street 1:32 COLLEGE AVE
Practice Address - Street 2:SUITE 206
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-6100
Practice Address - Country:US
Practice Address - Phone:207-680-2065
Practice Address - Fax:207-680-2068
Is Sole Proprietor?:No
Enumeration Date:2009-06-16
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC120631041C0700X
MELC13117104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1730316910Medicaid