Healthcare Provider Details

I. General information

NPI: 1003417668
Provider Name (Legal Business Name): BENJAMIN JAMES EHRENFELD LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2020
Last Update Date: 11/02/2020
Certification Date: 11/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 TRINITY ST
AUSTIN TX
78712-1765
US

IV. Provider business mailing address

803 E 47TH ST
AUSTIN TX
78751-3308
US

V. Phone/Fax

Practice location:
  • Phone: 512-495-5300
  • Fax:
Mailing address:
  • Phone: 716-308-8758
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number64867
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: