Basic Information
| Provider Information | |||||||||
| NPI: | 1730316910 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENTTINEN | ||||||||
| FirstName: | KERISH | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GRANT | ||||||||
| OtherFirstName: | KERISH | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 32 COLLEGE AVE | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | WATERVILLE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049016100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076802065 | ||||||||
| FaxNumber: | 2076802068 | ||||||||
| Practice Location | |||||||||
| Address1: | 32 COLLEGE AVE | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | WATERVILLE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049016100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076802065 | ||||||||
| FaxNumber: | 2076802068 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2009 | ||||||||
| LastUpdateDate: | 12/27/2011 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | MC12063 | ME | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | LC13117 | ME | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 1730316910 | 05 | ME | MEDICAID |