Provider Demographics
NPI:1417143272
Name:ANDERSON, BENJAMIN CHARLES (COTA)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:CHARLES
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 MITCHELL RD
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:TX
Mailing Address - Zip Code:75670-2254
Mailing Address - Country:US
Mailing Address - Phone:903-938-2863
Mailing Address - Fax:
Practice Address - Street 1:1010 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:TX
Practice Address - Zip Code:75652-2923
Practice Address - Country:US
Practice Address - Phone:903-657-6549
Practice Address - Fax:903-657-9061
Is Sole Proprietor?:No
Enumeration Date:2007-09-14
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX209816224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant