Provider Demographics
NPI:1558949099
Name:MICHON, BENJAMIN (ATC, LAT, CSCS)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:MICHON
Suffix:
Gender:M
Credentials:ATC, LAT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 WARREN AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:MARLBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01752-3989
Mailing Address - Country:US
Mailing Address - Phone:413-346-8717
Mailing Address - Fax:
Practice Address - Street 1:1844 COMMONWEALTH AVE
Practice Address - Street 2:
Practice Address - City:AUBURNDALE
Practice Address - State:MA
Practice Address - Zip Code:02466-2709
Practice Address - Country:US
Practice Address - Phone:617-243-2168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-29
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA33672081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine