Provider Demographics
NPI:1417919234
Name:BENETEAU, SHANA (PT)
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:
Last Name:BENETEAU
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 1:10 TOWER DR
Mailing Address - Street 2:
Mailing Address - City:SUN PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53590-1239
Mailing Address - Country:US
Mailing Address - Phone:608-825-3500
Mailing Address - Fax:608-825-3598
Practice Address - Street 1:10 TOWER DR
Practice Address - Street 2:
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-1239
Practice Address - Country:US
Practice Address - Phone:608-825-3500
Practice Address - Fax:608-825-3598
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6440225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1417919234Medicaid
WI81030Medicare PIN
WI0029Medicare ID - Type Unspecified
WI40328900Medicaid