Provider Demographics
NPI:1346474897
Name:BENSON, MAVIS M (PT)
Entity Type:Individual
Prefix:MS
First Name:MAVIS
Middle Name:M
Last Name:BENSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42412 US HIGHWAY 75 NW
Mailing Address - Street 2:
Mailing Address - City:STEPHEN
Mailing Address - State:MN
Mailing Address - Zip Code:56757-9608
Mailing Address - Country:US
Mailing Address - Phone:218-745-3235
Mailing Address - Fax:
Practice Address - Street 1:109 S MINNESOTA ST
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MN
Practice Address - Zip Code:56762-1428
Practice Address - Country:US
Practice Address - Phone:218-745-3235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-13
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1483225100000X
ND0285225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist