MEDICARE: DR. KEITH RICHARD BENOFF PH.D.

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	174400000X	Specialist	35SI00415100	NJ
2	103G00000X	Clinical Neuropsychologist	35S100415100	NJ
3	103T00000X	Psychologist	35S100415100	NJ

General Provider Information

NPI Number	:	1629073572
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEITH RICHARD BENOFF PH.D.

Provider Business Mailing Address
First Line	:	700 PALISADE AVENUE
Second Line	:
City	:	ENGLEWOOD CLIFFS
State	:	NJ
Zip	:	07632
Country	:	US
Telephone Number	:	201-568-3412
Fax Number	:	201-568-8249

Provider Business Practice Location Address
First Line	:	700 PALISADE AVENUE
Second Line	:
City	:	ENGLEWOOD CLIFFS
State	:	NJ
Zip	:	07632
Country	:	US
Telephone Number	:	201-568-3412
Fax Number	:	201-568-8249

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

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	04/11/2011

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