Provider Demographics
NPI:1407215528
Name:WHITE, BENJAMIN A (PT, DPT)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:A
Last Name:WHITE
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2516 FAIRWOOD CT
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-1765
Mailing Address - Country:US
Mailing Address - Phone:812-361-6212
Mailing Address - Fax:
Practice Address - Street 1:2516 FAIRWOOD CT
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-1765
Practice Address - Country:US
Practice Address - Phone:812-361-6212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-17
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA22202225100000X
CA292009225100000X
OHPT017332225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist