Provider Demographics
NPI:1508160144
Name:HENDERSON, BENTON CHASE (RECOVERY ASSISTANT)
Entity Type:Individual
Prefix:
First Name:BENTON
Middle Name:CHASE
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:RECOVERY ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1589
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72018-1589
Mailing Address - Country:US
Mailing Address - Phone:501-315-3344
Mailing Address - Fax:
Practice Address - Street 1:105 HWY 9
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:AR
Practice Address - Zip Code:72565-9749
Practice Address - Country:US
Practice Address - Phone:870-258-3244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-22
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator