Provider Demographics
NPI:1770629578
Name:BENNER, THOMAS PATRICK (LCADC, MS, MAC, SAP)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:PATRICK
Last Name:BENNER
Suffix:
Gender:M
Credentials:LCADC, MS, MAC, SAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8950 RTE 108
Mailing Address - Street 2:SUITE 235
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-2273
Mailing Address - Country:US
Mailing Address - Phone:443-812-2758
Mailing Address - Fax:
Practice Address - Street 1:8950 RTE 108
Practice Address - Street 2:SUITE 235
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-2273
Practice Address - Country:US
Practice Address - Phone:443-812-2758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLCA157101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD410405600Medicaid
MDLCA157OtherLICENSE