Basic Information
| Provider Information | |||||||||
| NPI: | 1700056512 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KUDLER | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1340 BOYLSTON ST | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022154302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6179276321 | ||||||||
| FaxNumber: | 6172673667 | ||||||||
| Practice Location | |||||||||
| Address1: | 1340 BOYLSTON ST | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022154302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6179276321 | ||||||||
| FaxNumber: | 6172673667 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2008 | ||||||||
| LastUpdateDate: | 04/17/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 115455 | MA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 221867 | 01 | MA | MEDICARE PART A | OTHER | 1303546 | 05 | MA | MEDICAID | Y10138 | 01 | MA | MEDICARE, PART B | OTHER |