Provider Demographics
NPI:1679080410
Name:BATES, BENJAMIN (OTR/L)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:BATES
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13236 FAWN LILY DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33579-0008
Mailing Address - Country:US
Mailing Address - Phone:937-681-0762
Mailing Address - Fax:
Practice Address - Street 1:8254 118TH AVE
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33773-5017
Practice Address - Country:US
Practice Address - Phone:727-541-5304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-02
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
15-04279106S00000X
FLOT20926225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
15-04279OtherREGISTERED BEHAVIOR TECHNICIAN