Provider Demographics
NPI:1497849194
Name:BENTON, KATHRYN A (PHD)
Entity Type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:A
Last Name:BENTON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 N WINFIELD RD
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190-1295
Mailing Address - Country:US
Mailing Address - Phone:630-933-6631
Mailing Address - Fax:630-933-2140
Practice Address - Street 1:25 N WINFIELD RD
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190-1295
Practice Address - Country:US
Practice Address - Phone:630-933-6631
Practice Address - Fax:630-933-2140
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-006442103TC2200X, 103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1033149844OtherGROUP NPI NUMBER
IL1497849194OtherNPI
IL3631498336019001OtherHFS GROUP PAYEE ID
IL0222075OtherBLUE CROSS GROUP NUMBER
IL363149833OtherGROUPTAX IDENTIFICATION NUMBER
IL0222075OtherBLUE CROSS GROUP NUMBER