Healthcare Provider Details

I. General information

NPI: 1477199503
Provider Name (Legal Business Name): BENTON DREW TOLLESON LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2019
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11863 STATE HIGHWAY 13
KIMBERLING CITY MO
65686-8362
US

IV. Provider business mailing address

1059 BARTON DR
FORDLAND MO
65652-7350
US

V. Phone/Fax

Practice location:
  • Phone: 417-739-1995
  • Fax: 417-739-1983
Mailing address:
  • Phone: 417-767-2273
  • Fax: 417-767-4054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2022019269
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: