Provider Demographics
NPI:1194010025
Name:SEYMOUR, BENJAMIN (CAC)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:SEYMOUR
Suffix:
Gender:M
Credentials:CAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4419 NORTH SUPAI AVE.
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646
Mailing Address - Country:US
Mailing Address - Phone:208-949-0363
Mailing Address - Fax:
Practice Address - Street 1:1833 MILLENNIUM WAY SUITE# 120
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642
Practice Address - Country:US
Practice Address - Phone:888-277-0068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-20
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA65027101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)