Healthcare Provider Details

I. General information

NPI: 1699286559
Provider Name (Legal Business Name): OTMAINE BENASSOU PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2017
Last Update Date: 10/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

669 CASTLETON AVE
STATEN ISLAND NY
10301-2028
US

IV. Provider business mailing address

14350 HOOVER AVE APT 303
BRIARWOOD NY
11435-2158
US

V. Phone/Fax

Practice location:
  • Phone: 718-442-2225
  • Fax: 718-442-2289
Mailing address:
  • Phone: 347-579-8495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF402232-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: