Provider Demographics
NPI:1104506294
Name:BENTON, BOONE LEONARD (PHD, LPC)
Entity type:Individual
Prefix:DR
First Name:BOONE
Middle Name:LEONARD
Last Name:BENTON
Suffix:
Gender:M
Credentials:PHD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:376 TALLY MOUNTAIN RD N
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:GA
Mailing Address - Zip Code:30143-4706
Mailing Address - Country:US
Mailing Address - Phone:770-846-8161
Mailing Address - Fax:
Practice Address - Street 1:376 TALLY MOUNTAIN RD N
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:GA
Practice Address - Zip Code:30143-4706
Practice Address - Country:US
Practice Address - Phone:770-846-8161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001999101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty