Provider Demographics
NPI:1073670857
Name:BENJAMIN, CARISSA (PT)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:
Last Name:BENJAMIN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 N HIGGINS AVE STE B
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802
Mailing Address - Country:US
Mailing Address - Phone:406-542-3333
Mailing Address - Fax:406-542-3365
Practice Address - Street 1:420 N HIGGINS AVE STE B
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4524
Practice Address - Country:US
Practice Address - Phone:406-542-3333
Practice Address - Fax:406-542-3365
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT2009PT225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist