Provider Demographics
NPI:1770696411
Name:BENTON, BOBBY JOE SR (AAS,CADC-I)
Entity type:Individual
Prefix:MR
First Name:BOBBY
Middle Name:JOE
Last Name:BENTON
Suffix:SR
Gender:M
Credentials:AAS,CADC-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 WILLOW DR # 34
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:OR
Mailing Address - Zip Code:97801-6021
Mailing Address - Country:US
Mailing Address - Phone:541-276-5941
Mailing Address - Fax:
Practice Address - Street 1:73265 CONFEDERATED WAY
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:OR
Practice Address - Zip Code:97801
Practice Address - Country:US
Practice Address - Phone:541-966-9830
Practice Address - Fax:541-278-7572
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR05-07-03101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR171037Medicaid