Provider Demographics
NPI:1891229878
Name:BENTON STREET COUNSELING LLC
Entity Type:Organization
Organization Name:BENTON STREET COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:NECOLE
Authorized Official - Middle Name:L
Authorized Official - Last Name:OLMSTEAD
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:573-525-7071
Mailing Address - Street 1:PO BOX 856
Mailing Address - Street 2:
Mailing Address - City:CAMDENTON
Mailing Address - State:MO
Mailing Address - Zip Code:65020-0856
Mailing Address - Country:US
Mailing Address - Phone:573-525-7071
Mailing Address - Fax:573-525-7072
Practice Address - Street 1:89 MCCRORY DRIVE
Practice Address - Street 2:
Practice Address - City:CAMDENTON
Practice Address - State:MO
Practice Address - Zip Code:65020
Practice Address - Country:US
Practice Address - Phone:573-525-7071
Practice Address - Fax:573-525-7072
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BENTON STREET COUNSELING LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-04-17
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012036248101YP2500X
MO2015043538101YP2500X
MO2016007581101YP2500X
MO2013023278101YP2500X
MO2015000875101YP2500X
MO2004020356101YP2500X
MO2014034465101YP2500X
MO2010030790103T00000X
MO20100361351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1932597721Medicaid