Provider Demographics
NPI:1942870894
Name:BENENSON, KATHERINE MIKKESLEN (LICSW)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:MIKKESLEN
Last Name:BENENSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:ANN
Other - Last Name:MIKKELSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:684 TREMONT ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-3179
Mailing Address - Country:US
Mailing Address - Phone:509-939-5018
Mailing Address - Fax:
Practice Address - Street 1:780 AMERICAN LEGION HWY
Practice Address - Street 2:
Practice Address - City:ROSLINDALE
Practice Address - State:MA
Practice Address - Zip Code:02131-3908
Practice Address - Country:US
Practice Address - Phone:617-469-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-01
Last Update Date:2025-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MA1285911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health