Provider Demographics
NPI:1659599462
Name:BENTON, RACHELLE S (PT)
Entity Type:Individual
Prefix:
First Name:RACHELLE
Middle Name:S
Last Name:BENTON
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 1:2416 HIGHWAY 45 N
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-1320
Mailing Address - Country:US
Mailing Address - Phone:662-327-6705
Mailing Address - Fax:662-327-6760
Practice Address - Street 1:1201 HIGHWAY 49 S
Practice Address - Street 2:SUITE 2
Practice Address - City:RICHLAND
Practice Address - State:MS
Practice Address - Zip Code:39218-9425
Practice Address - Country:US
Practice Address - Phone:769-233-8844
Practice Address - Fax:769-251-1825
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT978225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00126939Medicaid