Provider Demographics
NPI:1104848688
Name:BENZ, TONYA S
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:S
Last Name:BENZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6369 GOOSE LAKE DR
Mailing Address - Street 2:COMPLIANCE MAIL CODE-2433
Mailing Address - City:VERONA
Mailing Address - State:WI
Mailing Address - Zip Code:53593-9255
Mailing Address - Country:US
Mailing Address - Phone:608-848-1632
Mailing Address - Fax:
Practice Address - Street 1:6369 GOOSE LAKE DR
Practice Address - Street 2:COMPLIANCE MAIL CODE-2433
Practice Address - City:VERONA
Practice Address - State:WI
Practice Address - Zip Code:53593-9255
Practice Address - Country:US
Practice Address - Phone:608-848-1632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3877-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3877-26OtherOT