Provider Demographics
NPI:1740770361
Name:BENSON, BLAKE (LPC)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:BENSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4004 PEACH CREEK DR
Mailing Address - Street 2:
Mailing Address - City:WHARTON
Mailing Address - State:TX
Mailing Address - Zip Code:77488-9716
Mailing Address - Country:US
Mailing Address - Phone:832-621-7581
Mailing Address - Fax:
Practice Address - Street 1:4004 PEACH CREEK DR
Practice Address - Street 2:
Practice Address - City:WHARTON
Practice Address - State:TX
Practice Address - Zip Code:77488
Practice Address - Country:US
Practice Address - Phone:832-621-7581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-18
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX75171101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX75171OtherSTATE LICENSE