MEDICARE: MR. GARY WILLIAM BENA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	2005016662	MO

General Provider Information

NPI Number	:	1285801217
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GARY WILLIAM BENA

Provider Business Mailing Address
First Line	:	6126 TENNESSEE AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63111-2323
Country	:	US
Telephone Number	:	314-832-1082
Fax Number	:

Provider Business Practice Location Address
First Line	:	6126 TENNESSEE AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63111-2323
Country	:	US
Telephone Number	:	314-832-1082
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/08/2008
Last Update Date	:	05/08/2008

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