Provider Demographics
NPI:1164790366
Name:BENJAMIN, BETHANY LYNN (PTA)
Entity Type:Individual
Prefix:MISS
First Name:BETHANY
Middle Name:LYNN
Last Name:BENJAMIN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5821 STATE HIGHWAY 34
Mailing Address - Street 2:
Mailing Address - City:RUDOLPH
Mailing Address - State:WI
Mailing Address - Zip Code:54475-9587
Mailing Address - Country:US
Mailing Address - Phone:715-459-5255
Mailing Address - Fax:
Practice Address - Street 1:5821 STATE HIGHWAY 34
Practice Address - Street 2:
Practice Address - City:RUDOLPH
Practice Address - State:WI
Practice Address - Zip Code:54475-9587
Practice Address - Country:US
Practice Address - Phone:715-459-5255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-02
Last Update Date:2013-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1753-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1164790366Medicaid