Provider Demographics
NPI:1093483166
Name:BENTZ, LAURA J (PTA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:J
Last Name:BENTZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:J
Other - Last Name:REYNOLDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:PO BOX 1118
Mailing Address - Street 2:
Mailing Address - City:BASIN
Mailing Address - State:WY
Mailing Address - Zip Code:82410-1118
Mailing Address - Country:US
Mailing Address - Phone:614-634-6558
Mailing Address - Fax:
Practice Address - Street 1:1901 HOWELL AVE
Practice Address - Street 2:
Practice Address - City:WORLAND
Practice Address - State:WY
Practice Address - Zip Code:82401-3733
Practice Address - Country:US
Practice Address - Phone:307-347-4285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-02
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPTA1038225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant