MEDICARE: BENITA S PARK

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	129830	NY

General Provider Information

NPI Number	:	1578419073
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BENITA S PARK

Provider Business Mailing Address
First Line	:	282 BIRCHWOOD PARK DR
Second Line	:
City	:	JERICHO
State	:	NY
Zip	:	11753-2307
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	282 BIRCHWOOD PARK DR
Second Line	:
City	:	JERICHO
State	:	NY
Zip	:	11753-2307
Country	:	US
Telephone Number	:	631-392-8384
Fax Number	:

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

Provider Enumeration Date	:	03/06/2026
Last Update Date	:	03/06/2026

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Directions to “ BENITA S PARK ” Practice Location

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