Provider Demographics
NPI:1265840516
Name:WILT, BENJAMIN MICHAEL (PT, DPT, OCS)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:MICHAEL
Last Name:WILT
Suffix:
Gender:M
Credentials:PT, DPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13334 W MILL GROVE DR
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737-6564
Mailing Address - Country:US
Mailing Address - Phone:337-258-7127
Mailing Address - Fax:
Practice Address - Street 1:13334 W MILL GROVE DR
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-6564
Practice Address - Country:US
Practice Address - Phone:337-258-7127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-31
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA088102251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic