Healthcare Provider Details

I. General information

NPI: 1770195570
Provider Name (Legal Business Name): BENJAMIN STREET LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2020
Last Update Date: 03/31/2021
Certification Date: 03/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5130 E MAIN ST STE 2
BATAVIA NY
14020-3444
US

IV. Provider business mailing address

5130 E MAIN ST STE 2
BATAVIA NY
14020-3444
US

V. Phone/Fax

Practice location:
  • Phone: 585-344-1421
  • Fax:
Mailing address:
  • Phone: 585-344-1421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number111925-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: