Provider Demographics
NPI:1134511496
Name:BENJAMIN, BERNARD (COTA)
Entity Type:Individual
Prefix:MR
First Name:BERNARD
Middle Name:
Last Name:BENJAMIN
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 JEFFERSON ST NE
Mailing Address - Street 2:APT 36
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-1289
Mailing Address - Country:US
Mailing Address - Phone:772-318-8113
Mailing Address - Fax:
Practice Address - Street 1:5123 JUAN TABO BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-2672
Practice Address - Country:US
Practice Address - Phone:505-292-3333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-24
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3331224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant