Healthcare Provider Details

I. General information

NPI: 1376537860
Provider Name (Legal Business Name): ELLIOTT BENAY MA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 03/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 ALPINE DR
JERICHO VT
05465-2071
US

IV. Provider business mailing address

85 ALPINE DR
JERICHO VT
05465-2071
US

V. Phone/Fax

Practice location:
  • Phone: 802-899-3558
  • Fax: 802-899-1726
Mailing address:
  • Phone: 802-899-3558
  • Fax: 802-899-1726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number047-0000024
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: