Provider Demographics
NPI:1871206565
Name:BENTON, ANSON JR
Entity type:Individual
Prefix:
First Name:ANSON
Middle Name:
Last Name:BENTON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1917 JACKS CT
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32301-6077
Mailing Address - Country:US
Mailing Address - Phone:954-934-5152
Mailing Address - Fax:
Practice Address - Street 1:1725 HERMITAGE BLVD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-7709
Practice Address - Country:US
Practice Address - Phone:850-366-6997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-28
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBACB864615Medicaid