Healthcare Provider Details

I. General information

NPI: 1932597721
Provider Name (Legal Business Name): BENTON STREET COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2014
Last Update Date: 04/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 N BENTON ST
WAYNESVILLE MO
65583-2501
US

IV. Provider business mailing address

119 N BENTON ST
WAYNESVILLE MO
65583-2501
US

V. Phone/Fax

Practice location:
  • Phone: 573-433-2833
  • Fax: 573-433-2829
Mailing address:
  • Phone: 573-433-2833
  • Fax: 573-433-2829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2012036248
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2013015853
License Number StateMO

VIII. Authorized Official

Name: MARY ANN WYATT
Title or Position: MEMBER
Credential: LPC
Phone: 573-433-2833