Provider Demographics
NPI:1326264060
Name:JOHNSON, BENTON KURT II (PHD, LCPC, LMHC, NCC)
Entity Type:Individual
Prefix:DR
First Name:BENTON
Middle Name:KURT
Last Name:JOHNSON
Suffix:II
Gender:M
Credentials:PHD, LCPC, LMHC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2424 40TH AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-7215
Mailing Address - Country:US
Mailing Address - Phone:309-269-3100
Mailing Address - Fax:888-243-3903
Practice Address - Street 1:2424 40TH AVE APT 6
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-7215
Practice Address - Country:US
Practice Address - Phone:309-269-3100
Practice Address - Fax:888-243-3903
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2021-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180006524101YA0400X, 101YP2500X
IA001063101YM0800X
222Q00000X
IL180-006524101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208164344OtherEI PROVIDER #