Healthcare Provider Details

I. General information

NPI: 1518808237
Provider Name (Legal Business Name): BENJAMIN JAMES DIYENNO LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2026
Last Update Date: 04/06/2026
Certification Date: 04/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1387 CHEWS LANDING RD
CLEMENTON NJ
08021-2760
US

IV. Provider business mailing address

37 MOHAWK TRL
MEDFORD LAKES NJ
08055-1526
US

V. Phone/Fax

Practice location:
  • Phone: 855-857-6050
  • Fax:
Mailing address:
  • Phone: 609-922-3827
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number37AC00946200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: