Provider Demographics
NPI:1740519115
Name:BENTON, DAN LEWIS (LPC)
Entity type:Individual
Prefix:MR
First Name:DAN
Middle Name:LEWIS
Last Name:BENTON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9117 INDIAN CREEK DR
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73130-4265
Mailing Address - Country:US
Mailing Address - Phone:405-684-5884
Mailing Address - Fax:
Practice Address - Street 1:1212 S AIR DEPOT BLVD
Practice Address - Street 2:43
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-4870
Practice Address - Country:US
Practice Address - Phone:405-684-5884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-15
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3468101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health