MEDICARE: DR. BENJAMIN G DANIS PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	PY00001512	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DA0071	OTHER	WA	REGENCE PROVIDER #

General Provider Information

NPI Number	:	1225056369
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BENJAMIN G DANIS PH.D.

Provider Business Mailing Address
First Line	:	PO BOX 1119
Second Line	:
City	:	EDMONDS
State	:	WA
Zip	:	98020-1119
Country	:	US
Telephone Number	:	206-325-7774
Fax Number	:	425-771-0674

Provider Business Practice Location Address
First Line	:	4105 E MADISON ST
Second Line	:	SUITE 222
City	:	SEATTLE
State	:	WA
Zip	:	98112-3291
Country	:	US
Telephone Number	:	206-325-7774
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	07/08/2007

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