Provider Demographics
NPI:1891312062
Name:TONTI, BENITA (ALC)
Entity Type:Individual
Prefix:
First Name:BENITA
Middle Name:
Last Name:TONTI
Suffix:
Gender:F
Credentials:ALC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 12TH ST
Mailing Address - Street 2:
Mailing Address - City:PHENIX CITY
Mailing Address - State:AL
Mailing Address - Zip Code:36867-5818
Mailing Address - Country:US
Mailing Address - Phone:334-592-8080
Mailing Address - Fax:
Practice Address - Street 1:710 12TH ST
Practice Address - Street 2:
Practice Address - City:PHENIX CITY
Practice Address - State:AL
Practice Address - Zip Code:36867-5818
Practice Address - Country:US
Practice Address - Phone:334-592-8080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-02
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALC3306A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL00000000Medicaid