Provider Demographics
NPI:1104932383
Name:MCCONNELL, CHARLES BENTON (MA)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:BENTON
Last Name:MCCONNELL
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 N ALLUMBAUGH
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704
Mailing Address - Country:US
Mailing Address - Phone:208-658-0800
Mailing Address - Fax:208-323-1894
Practice Address - Street 1:413 N ALLUMBAUGH
Practice Address - Street 2:SUITE 103
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704
Practice Address - Country:US
Practice Address - Phone:208-658-0800
Practice Address - Fax:208-323-1894
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPCP 127101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor