Provider Demographics
NPI:1023620671
Name:WANTMAN, BENJAMIN (BCBA, MSED)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:WANTMAN
Suffix:
Gender:M
Credentials:BCBA, MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3010 118TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98005-4137
Mailing Address - Country:US
Mailing Address - Phone:203-417-8314
Mailing Address - Fax:
Practice Address - Street 1:929 109TH AVE NE
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-4404
Practice Address - Country:US
Practice Address - Phone:425-326-1545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-20-43340103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst