Healthcare Provider Details

I. General information

NPI: 1558350777
Provider Name (Legal Business Name): TODD L. BENHAM PSYD, ABPP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 12/17/2021
Certification Date: 12/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11050 MOUNT BELVEDERE BLVD
FORT DRUM NY
13602-5438
US

IV. Provider business mailing address

11050 MOUNT BELVEDERE BLVD
FORT DRUM NY
13602
US

V. Phone/Fax

Practice location:
  • Phone: 315-772-6890
  • Fax: 315-772-9243
Mailing address:
  • Phone: 315-772-4850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number016076
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: