Healthcare Provider Details

I. General information

NPI: 1730166596
Provider Name (Legal Business Name): ROBERT WILLIAM BENSON M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

STAR TREK DRIVE
WEST MILFORD WV
26451-0154
US

IV. Provider business mailing address

PO BOX 154 STAR TREK DRIVE
WEST MILFORD WV
26451-0154
US

V. Phone/Fax

Practice location:
  • Phone: 304-745-4710
  • Fax: 304-745-4710
Mailing address:
  • Phone: 304-745-4710
  • Fax: 304-745-4710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number265
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: