Basic Information
| Provider Information | |||||||||
| NPI: | 1225025588 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENTON | ||||||||
| FirstName: | BARBARA | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA, LCMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 86 LAKE ST | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054015297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028653450 | ||||||||
| FaxNumber: | 8028605011 | ||||||||
| Practice Location | |||||||||
| Address1: | 86 LAKE ST | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054015297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028653450 | ||||||||
| FaxNumber: | 8028605011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2005 | ||||||||
| LastUpdateDate: | 04/15/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 068-0000443 | VT | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1007162 | 05 | VT | MEDICAID |