Provider Demographics
NPI:1912599770
Name:BENJAMIN, KELLY M (MHC)
Entity type:Individual
Prefix:MR
First Name:KELLY
Middle Name:M
Last Name:BENJAMIN
Suffix:
Gender:M
Credentials:MHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:636 PLANK RD
Mailing Address - Street 2:
Mailing Address - City:CLIFTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12065-2046
Mailing Address - Country:US
Mailing Address - Phone:518-545-4691
Mailing Address - Fax:
Practice Address - Street 1:636 PLANK RD
Practice Address - Street 2:
Practice Address - City:CLIFTON PARK
Practice Address - State:NY
Practice Address - Zip Code:12065-2046
Practice Address - Country:US
Practice Address - Phone:518-545-4691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-03
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NY108665-01101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health