=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659042851
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MISTY MICHELLE BENTON M.S CCC/SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2021
-----------------------------------------------------
Last Update Date | 09/27/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2052 INDUSTRIAL BLVD
-----------------------------------------------------
City | ABILENE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79602-7832
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 325-437-8232
-----------------------------------------------------
Fax | 325-672-1376
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 190 OLIVIAS CT
-----------------------------------------------------
City | TUSCOLA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79562-3669
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 325-725-0980
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 18668
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------