Provider Demographics
NPI:1326537200
Name:BENSON, ANDREA LOUISE (DPT)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:LOUISE
Last Name:BENSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 VAN BUREN ST
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:WI
Mailing Address - Zip Code:53121-1221
Mailing Address - Country:US
Mailing Address - Phone:262-210-7079
Mailing Address - Fax:
Practice Address - Street 1:5700 MOCKINGBIRD LN
Practice Address - Street 2:
Practice Address - City:GREENDALE
Practice Address - State:WI
Practice Address - Zip Code:53129-1442
Practice Address - Country:US
Practice Address - Phone:414-622-1702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-06
Last Update Date:2018-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11226-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist