Healthcare Provider Details

I. General information

NPI: 1235689571
Provider Name (Legal Business Name): WILLIAM BENJAMIN ROY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2016
Last Update Date: 07/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 RODMAN RD
AUBURN ME
04210
US

IV. Provider business mailing address

63 DARNIT RD
BUCKFIELD ME
04220-4519
US

V. Phone/Fax

Practice location:
  • Phone: 207-376-3022
  • Fax:
Mailing address:
  • Phone: 207-602-9059
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPS1535
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-13-14831
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: