Provider Demographics
NPI:1518272152
Name:BENTON, MICHELLE PHILBROOK (LCMHCS, LCAS)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:PHILBROOK
Last Name:BENTON
Suffix:
Gender:F
Credentials:LCMHCS, LCAS
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 1
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28687-0001
Mailing Address - Country:US
Mailing Address - Phone:704-832-5567
Mailing Address - Fax:
Practice Address - Street 1:209 BARIUM SPRINGS DR
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-8454
Practice Address - Country:US
Practice Address - Phone:704-832-5567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-06
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20476101YA0400X
NC10290101YP2500X
NCS10290101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1518272152Medicaid