Provider Demographics
NPI:1811122963
Name:HARRIS, BENJAMIN G (MA, LCPC)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:G
Last Name:HARRIS
Suffix:
Gender:M
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2855 CORNWALL LN
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-4660
Mailing Address - Country:US
Mailing Address - Phone:815-761-4257
Mailing Address - Fax:
Practice Address - Street 1:1100 JORIE BLVD STE 132
Practice Address - Street 2:
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523
Practice Address - Country:US
Practice Address - Phone:630-522-3124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-19
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LCPC-LIC-11610101YP2500X
IL180007751101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional