Healthcare Provider Details

I. General information

NPI: 1790377125
Provider Name (Legal Business Name): BENJI SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2021
Last Update Date: 08/27/2021
Certification Date: 08/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 KITTY LN
CARBONDALE IL
62901-0013
US

IV. Provider business mailing address

75 KITTY LN
CARBONDALE IL
62901-0013
US

V. Phone/Fax

Practice location:
  • Phone: 618-201-3217
  • Fax:
Mailing address:
  • Phone: 618-201-3217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: