Provider Demographics
NPI:1790971208
Name:FAILOR, BENJAMIN JOSEPH (MSEC)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:JOSEPH
Last Name:FAILOR
Suffix:
Gender:M
Credentials:MSEC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:154 FORREST DR
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-5511
Mailing Address - Country:US
Mailing Address - Phone:573-221-2120
Mailing Address - Fax:573-221-4380
Practice Address - Street 1:154 FORREST DR
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-5511
Practice Address - Country:US
Practice Address - Phone:573-221-2120
Practice Address - Fax:573-221-4380
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-18
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019039992101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2019039992OtherSTATE OF MISSOURI