Healthcare Provider Details

I. General information

NPI: 1619940301
Provider Name (Legal Business Name): DEBRA HENRIETTE BENVENISTE MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2006
Last Update Date: 11/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1039 N MAIN ST
DAYVILLE CT
06241-2170
US

IV. Provider business mailing address

PO BOX 172 1039 NORTH MAIN STREET
DAYVILLE CT
06241
US

V. Phone/Fax

Practice location:
  • Phone: 860-774-2365
  • Fax:
Mailing address:
  • Phone: 860-774-2365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2203
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: