Provider Demographics
NPI:1770905655
Name:BENTON, BOHANAN ANTHONY
Entity type:Individual
Prefix:MR
First Name:BOHANAN
Middle Name:ANTHONY
Last Name:BENTON
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:BO
Other - Middle Name:ANTHONY
Other - Last Name:BENTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:320 ROBERT S KERR AVE
Mailing Address - Street 2:ROOM 505
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73102-3457
Mailing Address - Country:US
Mailing Address - Phone:405-713-1600
Mailing Address - Fax:405-235-1567
Practice Address - Street 1:320 ROBERT S KERR AVE
Practice Address - Street 2:ROOM 505
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73102-3457
Practice Address - Country:US
Practice Address - Phone:405-713-1600
Practice Address - Fax:405-235-1567
Is Sole Proprietor?:No
Enumeration Date:2014-01-13
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)