Provider Demographics
NPI:1629831417
Name:BENZON, TRISTAN
Entity Type:Individual
Prefix:
First Name:TRISTAN
Middle Name:
Last Name:BENZON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 S WOODLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-7646
Mailing Address - Country:US
Mailing Address - Phone:636-379-1779
Mailing Address - Fax:
Practice Address - Street 1:801 S WOODLAWN AVE
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-7646
Practice Address - Country:US
Practice Address - Phone:636-379-1779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023036734101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor