Provider Demographics
NPI:1972649689
Name:SLOTNICK, BENNETT STEVEN (PH D)
Entity Type:Individual
Prefix:
First Name:BENNETT
Middle Name:STEVEN
Last Name:SLOTNICK
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 OCEAN AVE
Mailing Address - Street 2:PO BOX 310
Mailing Address - City:OLD ORCHARD BEACH
Mailing Address - State:ME
Mailing Address - Zip Code:04064-2407
Mailing Address - Country:US
Mailing Address - Phone:207-934-5858
Mailing Address - Fax:207-934-6111
Practice Address - Street 1:10 STORER ST
Practice Address - Street 2:
Practice Address - City:KENNEBUNK
Practice Address - State:ME
Practice Address - Zip Code:04043-6875
Practice Address - Country:US
Practice Address - Phone:207-467-8215
Practice Address - Fax:207-604-5024
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1718103G00000X, 103TC0700X, 103TC2200X
NH310103G00000X, 103TC0700X, 103TC2200X
MEPS921103G00000X, 103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA294560099Medicaid
MA294560099Medicaid
OTH000Medicare UPIN