Provider Demographics
NPI:1457483828
Name:BENJAMIN, JULIE NICOLE (OT)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:NICOLE
Last Name:BENJAMIN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 188
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MS
Mailing Address - Zip Code:38843-0188
Mailing Address - Country:US
Mailing Address - Phone:662-862-3070
Mailing Address - Fax:662-862-4970
Practice Address - Street 1:204 WHEELER DR
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:MS
Practice Address - Zip Code:38843-8900
Practice Address - Country:US
Practice Address - Phone:662-862-3070
Practice Address - Fax:662-862-4970
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT1707225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist