Provider Demographics
NPI:1790377125
Name:SMITH, BENJI
Entity Type:Individual
Prefix:
First Name:BENJI
Middle Name:
Last Name:SMITH
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 1:75 KITTY LN
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-0013
Mailing Address - Country:US
Mailing Address - Phone:618-201-3217
Mailing Address - Fax:
Practice Address - Street 1:75 KITTY LN
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-0013
Practice Address - Country:US
Practice Address - Phone:618-201-3217
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-08
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106S00000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101Y00000XBehavioral Health & Social Service ProvidersCounselor