MEDICARE: BENJAMIN P DETTER BS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor

General Provider Information

NPI Number	:	1255082616
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BENJAMIN P DETTER BS

Provider Business Mailing Address
First Line	:	202 PLUM ST APT 2
Second Line	:
City	:	ERIE
State	:	PA
Zip	:	16507-2640
Country	:	US
Telephone Number	:	814-490-8764
Fax Number	:

Provider Business Practice Location Address
First Line	:	4906 RICHMOND ST
Second Line	:
City	:	ERIE
State	:	PA
Zip	:	16509-1978
Country	:	US
Telephone Number	:	814-864-4226
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/17/2022
Last Update Date	:	01/17/2022

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Directions to “ BENJAMIN P DETTER BS” Practice Location

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