Provider Demographics
NPI:1467298257
Name:CLARK, BENJAMIN (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1204 KINGSBURY RD
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61571-1213
Mailing Address - Country:US
Mailing Address - Phone:309-253-4519
Mailing Address - Fax:
Practice Address - Street 1:1204 KINGSBURY RD
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IL
Practice Address - Zip Code:61571-1213
Practice Address - Country:US
Practice Address - Phone:309-253-4519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-02
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209029848363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health