Provider Demographics
NPI:1184824195
Name:BENBROOK, CARLA JUNE (COTA/L)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:JUNE
Last Name:BENBROOK
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 161
Mailing Address - Street 2:
Mailing Address - City:CROFTON
Mailing Address - State:KY
Mailing Address - Zip Code:42217-0161
Mailing Address - Country:US
Mailing Address - Phone:270-424-5843
Mailing Address - Fax:
Practice Address - Street 1:SHADY LAWN
Practice Address - Street 2:2582 CERULEAN RD
Practice Address - City:CADIZ
Practice Address - State:KY
Practice Address - Zip Code:42211
Practice Address - Country:US
Practice Address - Phone:270-522-3236
Practice Address - Fax:270-522-0825
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-19
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA3592224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant