Provider Demographics
NPI:1669851614
Name:BENTON-BLACK, KATHERINE ELIZABETH
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ELIZABETH
Last Name:BENTON-BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:ELIZABETH
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:379 EL TAMPA RD
Mailing Address - Street 2:
Mailing Address - City:CAMDENTON
Mailing Address - State:MO
Mailing Address - Zip Code:65020-4338
Mailing Address - Country:US
Mailing Address - Phone:573-280-6258
Mailing Address - Fax:888-758-0823
Practice Address - Street 1:379 EL TAMPA RD
Practice Address - Street 2:
Practice Address - City:CAMDENTON
Practice Address - State:MO
Practice Address - Zip Code:65020-4338
Practice Address - Country:US
Practice Address - Phone:573-280-6258
Practice Address - Fax:888-758-0823
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-22
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001021506225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1346653672OtherNPI UNDER ABILITY NETWORK ORGANIZATION