Healthcare Provider Details

I. General information

NPI: 1306501424
Provider Name (Legal Business Name): RAYMOND CARR BENTON JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2021
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3656 MCCONNELL RD APT 2A
GREENSBORO NC
27405-9784
US

IV. Provider business mailing address

PO BOX 3541
GREENSBORO NC
27402-3541
US

V. Phone/Fax

Practice location:
  • Phone: 336-962-1220
  • Fax:
Mailing address:
  • Phone: 336-962-1220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA19716
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: