Basic Information
Provider Information
NPI: 1003142092
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BENTON
FirstName: SARAH
MiddleName: A
NamePrefix:  
NameSuffix:  
Credential: LMHC
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 25 ALDWORTH ST
Address2: #1
City: JAMAICA PLAIN
State: MA
PostalCode: 021302715
CountryCode: US
TelephoneNumber: 5088300012
FaxNumber: 5088300092
Practice Location
Address1: 34 MAIN STREET EXT
Address2: SUITE 103
City: PLYMOUTH
State: MA
PostalCode: 023608302
CountryCode: US
TelephoneNumber: 5088300012
FaxNumber: 5088300092
Other Information
ProviderEnumerationDate: 10/26/2009
LastUpdateDate: 10/26/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YM0800X6339MAY Behavioral Health & Social Service ProvidersCounselorMental Health

No ID Information.


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