Healthcare Provider Details

I. General information

NPI: 1386115434
Provider Name (Legal Business Name): BENJAMIN MASON JUDY PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2018
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

713 HARRISON ST
SYRACUSE NY
13210-2305
US

IV. Provider business mailing address

713 HARRISON ST
SYRACUSE NY
13210-2305
US

V. Phone/Fax

Practice location:
  • Phone: 802-952-0367
  • Fax:
Mailing address:
  • Phone: 802-952-0367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberP146327
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: