Provider Demographics
NPI:1124459037
Name:WALL, BENJAMIN A (MA, LPC)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:A
Last Name:WALL
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 E MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:MO
Mailing Address - Zip Code:65010
Mailing Address - Country:US
Mailing Address - Phone:573-250-2210
Mailing Address - Fax:
Practice Address - Street 1:307 E MAIN STREET
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:MO
Practice Address - Zip Code:65010
Practice Address - Country:US
Practice Address - Phone:573-250-2210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-02
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015026369101Y00000X
101YM0800X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490025698Medicaid