Provider Demographics
NPI:1578053955
Name:BENTON STREET COUNSELING LLC
Entity Type:Organization
Organization Name:BENTON STREET COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:573-433-2833
Mailing Address - Street 1:1030 KINGSHIGHWAY ST STE A
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-2930
Mailing Address - Country:US
Mailing Address - Phone:573-458-9920
Mailing Address - Fax:573-433-2829
Practice Address - Street 1:1030 KINGSHIGHWAY ST STE A
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-2930
Practice Address - Country:US
Practice Address - Phone:573-458-9920
Practice Address - Fax:573-433-2829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-11
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000281101YM0800X
MO2017011362101YP2500X
MO20100361351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty