Provider Demographics
NPI:1568852861
Name:BENJAMIN, DEANA MARIE (MS PT)
Entity Type:Individual
Prefix:
First Name:DEANA
Middle Name:MARIE
Last Name:BENJAMIN
Suffix:
Gender:F
Credentials:MS PT
Other - Prefix:
Other - First Name:DEANA
Other - Middle Name:MARIE
Other - Last Name:FRIESEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS PT
Mailing Address - Street 1:PO BOX 339
Mailing Address - Street 2:
Mailing Address - City:PECOS
Mailing Address - State:NM
Mailing Address - Zip Code:87552-0339
Mailing Address - Country:US
Mailing Address - Phone:402-415-1987
Mailing Address - Fax:505-426-3956
Practice Address - Street 1:104 LEGION DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4804
Practice Address - Country:US
Practice Address - Phone:505-426-3955
Practice Address - Fax:505-426-3956
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-26
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4094225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist