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General NPI Number Information
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NPI Number | 1639358039
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Entity Type | Individual
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Provider Name | JOHN D BENTON LCSW
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Gender | Male
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Dates
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Enumeration Date | 11/01/2007
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Last Update Date | 03/04/2024
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Provider Practice Location Address
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Address Line | 9308 BALDWIN DR
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City | MACHESNEY PARK
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State | IL
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Zip | 61115-1720
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Country | US
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Telephone | 779-537-4631
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Fax |
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Provider Business Mailing Address
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Address Line | 9308 BALDWIN DR
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City | MACHESNEY PARK
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State | IL
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Zip | 61115-1720
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Country | US
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Telephone | 779-537-4631
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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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 149.012605
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License Number State | IL
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