MEDICARE: CARMEN L BENEDICT MS, BCBA

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	103K00000X	Behavior Analyst	146.0134188	VT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	146.0134188	OTHER	VT	BCBA LISENCE

General Provider Information

NPI Number	:	1639767510
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARMEN L BENEDICT MS, BCBA

Provider Business Mailing Address
First Line	:	124 E PONDEROSA CIR
Second Line	:
City	:	BRANDON
State	:	SD
Zip	:	57005-1900
Country	:	US
Telephone Number	:	810-434-5334
Fax Number	:

Provider Business Practice Location Address
First Line	:	2542 VT ROUTE
Second Line	:
City	:	NEWPORT CENTER
State	:	VT
Zip	:	05857
Country	:	US
Telephone Number	:	802-487-9421
Fax Number	:

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

Provider Enumeration Date	:	01/06/2021
Last Update Date	:	01/06/2021

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