Provider Demographics
NPI:1467838151
Name:BENSON, AMANDA (MA, LCPC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:BENSON
Suffix:
Gender:F
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 MONTEREY DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-2833
Mailing Address - Country:US
Mailing Address - Phone:618-830-8146
Mailing Address - Fax:618-206-8476
Practice Address - Street 1:1161 FORTUNE BLVD
Practice Address - Street 2:SUITE 400
Practice Address - City:SHILOH
Practice Address - State:IL
Practice Address - Zip Code:62269-7385
Practice Address - Country:US
Practice Address - Phone:618-830-8146
Practice Address - Fax:618-206-8476
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-04
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.008106101YP2500X
MO2009032848101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional