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
119 N BENTON ST, WAYNESVILLE, MO 65583-2501
(573) 433-2833
(573) 433-2829
Mailing address
119 N BENTON ST, WAYNESVILLE, MO 65583-2501
(573) 433-2833
(573) 433-2829
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
Primary
—
—
101YP2500X
Professional Counselor
2012036248
MO
1041C0700X
Clinical Social Worker
2013015853
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1932597721
—
MO
Enumeration date
12/31/2014
Last updated
04/13/2017
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