Provider Demographics
NPI:1811305527
Name:BENSON, THERESA (PHD)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:BENSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1910 MCDONALD DR
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-6055
Mailing Address - Country:US
Mailing Address - Phone:330-432-3479
Mailing Address - Fax:
Practice Address - Street 1:1910 MCDONALD DR
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-6055
Practice Address - Country:US
Practice Address - Phone:330-432-3479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-25
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071008398103TC1900X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling