Provider Demographics
NPI:1518384205
Name:STOVER, BENJAMIN ALEXANDER (MA, LCPC)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:ALEXANDER
Last Name:STOVER
Suffix:
Gender:M
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 1:3166 N LINCOLN AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-3133
Mailing Address - Country:US
Mailing Address - Phone:708-567-4252
Mailing Address - Fax:
Practice Address - Street 1:3166 N LINCOLN AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-3133
Practice Address - Country:US
Practice Address - Phone:708-567-4252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-20
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.008899101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health