Provider Demographics
NPI:1104699099
Name:BENJAMIN, COREY D (CADC, CRM, QMHA)
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:D
Last Name:BENJAMIN
Suffix:
Gender:M
Credentials:CADC, CRM, QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 SW CEDAR HILLS BLVD STE 170
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-2020
Mailing Address - Country:US
Mailing Address - Phone:503-626-1800
Mailing Address - Fax:
Practice Address - Street 1:3800 SW CEDAR HILLS BLVD STE 170
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-2020
Practice Address - Country:US
Practice Address - Phone:503-626-1800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-01
Last Update Date:2024-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23-QMHA-R-4572101YM0800X
OR23-CRM-2525175T00000X
ORT-22-2156101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORT-22-2156OtherMHACBO CADC
OR23-CRM-2525OtherMHACBO CRM
OR500841524Medicaid
OR23-QMHA-R-4572OtherMHACBO QMHA