Provider Demographics
NPI:1730558099
Name:BLUITT, BENJAMIN (LCDCII)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:BLUITT
Suffix:
Gender:M
Credentials:LCDCII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-5533
Mailing Address - Country:US
Mailing Address - Phone:567-316-7253
Mailing Address - Fax:567-316-7232
Practice Address - Street 1:919 MADISON AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43604-5533
Practice Address - Country:US
Practice Address - Phone:567-316-7253
Practice Address - Fax:567-316-7232
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-16
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDC.091076-2101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0119089Medicaid