Provider Demographics
NPI:1316598964
Name:BENSON, TINA
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:
Last Name:BENSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2478 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-5406
Mailing Address - Country:US
Mailing Address - Phone:260-387-6369
Mailing Address - Fax:260-387-6370
Practice Address - Street 1:2478 LAKE AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5406
Practice Address - Country:US
Practice Address - Phone:260-387-6369
Practice Address - Fax:260-387-6370
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-25
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
253Z00000X, 372600000X, 376J00000X
IN19-012089-13747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No253Z00000XAgenciesIn Home Supportive Care
No372600000XNursing Service Related ProvidersAdult Companion
No376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200937350AMedicaid