Provider Demographics
NPI:1770944480
Name:BENSON, STACY (LADC)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:BENSON
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 BEAVER BROOK RD
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-6239
Mailing Address - Country:US
Mailing Address - Phone:203-743-7574
Mailing Address - Fax:
Practice Address - Street 1:60 BEAVER BROOK RD
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-6239
Practice Address - Country:US
Practice Address - Phone:203-743-7574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-09
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001190101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001190OtherCONNECTICUT DEPARTMENT OF PUBLIC HEALTH