Provider Demographics
NPI:1306174701
Name:GAY, BENETTA N (ATC)
Entity type:Individual
Prefix:
First Name:BENETTA
Middle Name:N
Last Name:GAY
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:BENETTA
Other - Middle Name:N
Other - Last Name:FERGUSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:42 FRASIER FIR LN
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:SC
Mailing Address - Zip Code:29045-8532
Mailing Address - Country:US
Mailing Address - Phone:803-608-8820
Mailing Address - Fax:
Practice Address - Street 1:104 SALUDA POINTE DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-7295
Practice Address - Country:US
Practice Address - Phone:803-227-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-23
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5662255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer