Provider Demographics
NPI:1083068647
Name:BENTON, NICOLE N (LPC)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:N
Last Name:BENTON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3826 SALEM RD # 136
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30016-4528
Mailing Address - Country:US
Mailing Address - Phone:678-561-3091
Mailing Address - Fax:404-795-8974
Practice Address - Street 1:1194 147TH ST STE 5
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:GA
Practice Address - Zip Code:31064-8068
Practice Address - Country:US
Practice Address - Phone:678-561-3091
Practice Address - Fax:404-795-8974
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-20
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 101YM0800X
GA0076821041C0700X
GA008941101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003181947JMedicaid