=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265463616
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FREDERICK SAMUEL BENNER PH.D., LPC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2006
-----------------------------------------------------
Last Update Date | 07/17/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27 N BROWN ST
-----------------------------------------------------
City | LEWISTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17044-1734
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-242-1428
-----------------------------------------------------
Fax | 717-248-1937
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 429 HAPPY HOLLOW RD
-----------------------------------------------------
City | MIFFLINTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17059-8230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-242-1428
-----------------------------------------------------
Fax | 717-248-1937
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | PC003860
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------