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Organization

BENTON STREET COUNSELING LLC

Active
Organization subpart
No

Provider details

NPI number
Authorized official
MARY ANN WYATT LPC (MEMBER)
(573) 433-2833
Entity
Organization

Contact information

Practice address
1030 KINGSHIGHWAY ST STE A, ROLLA, MO 65401-2930
(573) 458-9920
(573) 433-2829
Mailing address
1030 KINGSHIGHWAY ST STE A, ROLLA, MO 65401-2930
(573) 458-9920
(573) 433-2829

Taxonomy

Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
000281
MO
101YP2500X
Professional Counselor
Primary
2017011362
MO
1041C0700X
Clinical Social Worker
2010036135
MO

Other

Enumeration date
05/11/2018
Last updated
05/11/2018
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