=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477920775
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KERISH BENTTINEN LCSW, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2015
-----------------------------------------------------
Last Update Date | 08/22/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 179 MAIN ST SUITE 401
-----------------------------------------------------
City | WATERVILLE
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04901-6672
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-649-9772
-----------------------------------------------------
Fax | 207-616-0577
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11 1ST RANGEWAY
-----------------------------------------------------
City | WATERVILLE
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04901-5161
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-649-9772
-----------------------------------------------------
Fax | 207-616-0577
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KERISH BENTTINEN
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 207-649-9772
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | LC13117
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------