Healthcare Provider Details

I. General information

NPI: 1356834543
Provider Name (Legal Business Name): TODD A BENSON CDP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2018
Last Update Date: 09/07/2022
Certification Date: 09/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 NE MAPLE ST
PULLMAN WA
99163-4120
US

IV. Provider business mailing address

340 NE MAPLE ST
PULLMAN WA
99163-4120
US

V. Phone/Fax

Practice location:
  • Phone: 509-334-1133
  • Fax:
Mailing address:
  • Phone: 509-334-1133
  • Fax: 509-332-1608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberCG61105894
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP60081261
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier101Y99995L
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: