Provider Demographics
NPI:1700300894
Name:BENANTE, MARTIN
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:BENANTE
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 1:603 CONCORD AVE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-1197
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:173 CHELSEA ST
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:MA
Practice Address - Zip Code:02149-4632
Practice Address - Country:US
Practice Address - Phone:908-303-7151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-31
Last Update Date:2017-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ101YM0800X, 101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA100220556979Medicaid