=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396522280
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREW BENJAMIN LLMSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2023
-----------------------------------------------------
Last Update Date | 09/13/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3353 TACOMA CIR
-----------------------------------------------------
City | ANN ARBOR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48108-1769
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-277-4634
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3353 TACOMA CIR
-----------------------------------------------------
City | ANN ARBOR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48108-1769
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-277-4634
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 6851116741
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------