MEDICARE: BENJAMIN W DEGIULIO LPC

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	101YP2500X	Professional Counselor	LPC-4963	ID
2	101YP2500X	Professional Counselor	C3425	OR

General Provider Information

NPI Number	:	1326395476
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BENJAMIN W DEGIULIO LPC

Provider Business Mailing Address
First Line	:	PO BOX 4908
Second Line	:
City	:	POCATELLO
State	:	ID
Zip	:	83205-4908
Country	:	US
Telephone Number	:	208-236-1600
Fax Number	:

Provider Business Practice Location Address
First Line	:	110 BEAVERCREEK RD
Second Line	:
City	:	OREGON CITY
State	:	OR
Zip	:	97045-4307
Country	:	US
Telephone Number	:	503-655-8471
Fax Number	:

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

Provider Enumeration Date	:	08/08/2012
Last Update Date	:	10/04/2017

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