Healthcare Provider Details

I. General information

NPI: 1255659918
Provider Name (Legal Business Name): BENJAMIN KEITH CONFORTI PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2010
Last Update Date: 02/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 PLEASANT HOME RD BLDG G1
AUGUSTA GA
30907-0518
US

IV. Provider business mailing address

211 PLEASANT HOME RD BLDG G1
AUGUSTA GA
30907-0518
US

V. Phone/Fax

Practice location:
  • Phone: 706-364-5228
  • Fax: 706-364-5229
Mailing address:
  • Phone: 706-364-5228
  • Fax: 706-364-5229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY003356
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number36033
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: