Provider Demographics
NPI:1639615495
Name:BENTON, LAKESHIA
Entity Type:Individual
Prefix:
First Name:LAKESHIA
Middle Name:
Last Name:BENTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4903 TUPELO AVE
Mailing Address - Street 2:
Mailing Address - City:PASCAGOULA
Mailing Address - State:MS
Mailing Address - Zip Code:39581-4101
Mailing Address - Country:US
Mailing Address - Phone:228-990-3484
Mailing Address - Fax:
Practice Address - Street 1:106 SMART PL
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-2040
Practice Address - Country:US
Practice Address - Phone:504-241-6006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-17
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health