Provider Demographics
NPI:1619300357
Name:STANLEY, BENJAMIN (LAC)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:STANLEY
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 WELLNESS WAY
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71913-6478
Mailing Address - Country:US
Mailing Address - Phone:501-624-7111
Mailing Address - Fax:
Practice Address - Street 1:125 WELLNESS WAY
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913-6478
Practice Address - Country:US
Practice Address - Phone:501-624-7111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-16
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA1709285101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR232124795Medicaid