MEDICARE: MR. BENJAMIN THEODORE DESCOTEAUX M.ED.

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	101YM0800X	Mental Health Counselor	LH00009254	WA
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	CP00001300	WA
3	101Y00000X	Counselor	RC00030840	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255440376
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BENJAMIN THEODORE DESCOTEAUX M.ED.

Provider Business Mailing Address
First Line	:	1007 KOALA AVE
Second Line	:
City	:	OMAK
State	:	WA
Zip	:	98841-9247
Country	:	US
Telephone Number	:	509-826-6191
Fax Number	:	509-826-8560

Provider Business Practice Location Address
First Line	:	1007 KOALA AVE
Second Line	:
City	:	OMAK
State	:	WA
Zip	:	98841-9247
Country	:	US
Telephone Number	:	509-826-6191
Fax Number	:	509-826-8560

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

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	11/11/2008

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