Healthcare Provider Details

I. General information

NPI: 1104490804
Provider Name (Legal Business Name): BENJAMIN BOESE LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2021
Last Update Date: 03/12/2022
Certification Date: 03/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

359 BALLSTON AVE
SARATOGA SPRINGS NY
12866-4723
US

IV. Provider business mailing address

359 BALLSTON AVE
SARATOGA SPRINGS NY
12866-4723
US

V. Phone/Fax

Practice location:
  • Phone: 518-587-8008
  • Fax:
Mailing address:
  • Phone: 518-587-8008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number112290
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: