Provider Demographics
NPI:1518547918
Name:PETSBURGH THERAPY SERVICES LLC
Entity Type:Organization
Organization Name:PETSBURGH THERAPY SERVICES LLC
Other - Org Name:CANDACE D BENNER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/TRAUMA SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:CANDACE
Authorized Official - Middle Name:D
Authorized Official - Last Name:BENNER
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC, CCTP, EMDR
Authorized Official - Phone:573-315-3848
Mailing Address - Street 1:PO BOX 114
Mailing Address - Street 2:
Mailing Address - City:ROBY
Mailing Address - State:MO
Mailing Address - Zip Code:65557-0114
Mailing Address - Country:US
Mailing Address - Phone:573-315-3448
Mailing Address - Fax:573-312-3848
Practice Address - Street 1:19871 SACKETT LN
Practice Address - Street 2:
Practice Address - City:WAYNESVILLE
Practice Address - State:MO
Practice Address - Zip Code:65583-3510
Practice Address - Country:US
Practice Address - Phone:573-315-3848
Practice Address - Fax:573-312-3848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-09
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1467869156OtherNPI