Provider Demographics
NPI:1790082162
Name:BENTON, CHARLES SAMUEL
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:SAMUEL
Last Name:BENTON
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 1:8200 GEORGIA ST
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-6227
Mailing Address - Country:US
Mailing Address - Phone:219-791-1400
Mailing Address - Fax:219-791-1422
Practice Address - Street 1:8200 GEORGIA ST
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-6227
Practice Address - Country:US
Practice Address - Phone:219-791-1400
Practice Address - Fax:219-791-1422
Is Sole Proprietor?:No
Enumeration Date:2011-02-22
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst