Basic Information
| Provider Information | |||||||||
| NPI: | 1285872390 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENGE | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | B.S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 211 W OREGON ST | ||||||||
| Address2: | |||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618014453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479773268 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1801 FOX DR | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618207236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173988080 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2009 | ||||||||
| LastUpdateDate: | 01/27/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.