Healthcare Provider Details

I. General information

NPI: 1730978958
Provider Name (Legal Business Name): MUSTAPHA BENSOUDA LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2025
Last Update Date: 05/05/2025
Certification Date: 05/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1239 BOSTON RD
BRONX NY
10456-3614
US

IV. Provider business mailing address

1239 BOSTON RD
BRONX NY
10456-3614
US

V. Phone/Fax

Practice location:
  • Phone: 551-751-0065
  • Fax:
Mailing address:
  • Phone: 646-410-1426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number124658-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: