Provider Demographics
NPI:1013553742
Name:BENCOMO, ANTHONY (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:
Last Name:BENCOMO
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10901 SW 106TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33176-3440
Mailing Address - Country:US
Mailing Address - Phone:305-632-5950
Mailing Address - Fax:
Practice Address - Street 1:5725 NW 186TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33015-6019
Practice Address - Country:US
Practice Address - Phone:305-625-9857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-18
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT10450225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist