Provider Demographics
NPI:1104998772
Name:BENJAMIN, WALTRAUT M (MSW LICSW)
Entity type:Individual
Prefix:MRS
First Name:WALTRAUT
Middle Name:M
Last Name:BENJAMIN
Suffix:
Gender:F
Credentials:MSW LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 NEW ST
Mailing Address - Street 2:
Mailing Address - City:REHOBOTH
Mailing Address - State:MA
Mailing Address - Zip Code:02769-2911
Mailing Address - Country:US
Mailing Address - Phone:508-252-4861
Mailing Address - Fax:508-252-4861
Practice Address - Street 1:105 MEDWAY ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-4401
Practice Address - Country:US
Practice Address - Phone:401-578-3666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISWOO1641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI3821-8Medicare UPIN
MAPO4934-80Medicare UPIN