Provider Demographics
NPI:1003277336
Name:BENICK, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:BENICK
Suffix:
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 1:1522 HANNUM DR
Mailing Address - Street 2:
Mailing Address - City:STREETSBORO
Mailing Address - State:OH
Mailing Address - Zip Code:44241-5194
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10701 EAST BLVD
Practice Address - Street 2:5M-690E EUL
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1702
Practice Address - Country:US
Practice Address - Phone:216-791-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-15
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH65373174400000X, 225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist
No174400000XOther Service ProvidersSpecialist