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General NPI Number Information
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NPI Number | 1104506294
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Entity Type | Individual
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Provider Name | BOONE LEONARD BENTON PH.D., LPC
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Gender | Male
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Dates
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Enumeration Date | 07/24/2023
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Last Update Date | 07/24/2023
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Provider Practice Location Address
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Address Line | 376 TALLY MOUNTAIN RD N
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City | JASPER
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State | GA
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Zip | 30143-4706
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Country | US
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Telephone | 770-846-8161
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Fax |
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Provider Business Mailing Address
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Address Line | 376 TALLY MOUNTAIN RD N
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City | JASPER
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State | GA
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Zip | 30143-4706
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Country | US
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Telephone | 770-846-8161
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 001999
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License Number State | GA
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