MEDICARE: DR. TODD L. BENHAM PSYD, ABPP

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	103TC0700X	Clinical Psychologist	016076	NY

General Provider Information

NPI Number	:	1558350777
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TODD L. BENHAM PSYD, ABPP

Provider Business Mailing Address
First Line	:	11050 MOUNT BELVEDERE BLVD
Second Line	:
City	:	FORT DRUM
State	:	NY
Zip	:	13602
Country	:	US
Telephone Number	:	315-772-4850
Fax Number	:

Provider Business Practice Location Address
First Line	:	11050 MOUNT BELVEDERE BLVD
Second Line	:
City	:	FORT DRUM
State	:	NY
Zip	:	13602-5438
Country	:	US
Telephone Number	:	315-772-6890
Fax Number	:	315-772-9243

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

Provider Enumeration Date	:	10/20/2005
Last Update Date	:	12/17/2021

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