Healthcare Provider Details

I. General information

NPI: 1245532639
Provider Name (Legal Business Name): ANNE L BOFFOLI BENTZEN LCSW PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2010
Last Update Date: 01/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 DUKE DR
CARMEL NY
10512-1598
US

IV. Provider business mailing address

153 DUKE DR
CARMEL NY
10512-1598
US

V. Phone/Fax

Practice location:
  • Phone: 845-519-5415
  • Fax:
Mailing address:
  • Phone: 845-519-5415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR048664-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberR048664-1
License Number StateNY

VIII. Authorized Official

Name: ANNE L BOFFOLI BENTZEN LCSW PLLC
Title or Position: SOLE MANAGING MEMBER OF PLLC
Credential: LCSW
Phone: 845-519-5415