Healthcare Provider Details

I. General information

NPI: 1124459037
Provider Name (Legal Business Name): BENJAMIN A WALL MA, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2013
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 N MAIN ST
ASHLAND MO
65010-9701
US

IV. Provider business mailing address

200 N MAIN ST
ASHLAND MO
65010-9701
US

V. Phone/Fax

Practice location:
  • Phone: 573-250-2210
  • Fax:
Mailing address:
  • Phone: 573-250-2210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2015026369
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: