Provider Demographics
NPI:1942865142
Name:COLL, BENJAMIN HUBBARD (BCBA)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:HUBBARD
Last Name:COLL
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25303-1231
Mailing Address - Country:US
Mailing Address - Phone:304-720-3383
Mailing Address - Fax:304-720-3781
Practice Address - Street 1:325 6TH AVE
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25303-1231
Practice Address - Country:US
Practice Address - Phone:304-720-3383
Practice Address - Fax:304-720-3781
Is Sole Proprietor?:No
Enumeration Date:2019-05-03
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1-19-35726103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst