Provider Demographics
NPI:1700225000
Name:BENBOW, LAQUETTA L (OTR/L)
Entity Type:Individual
Prefix:
First Name:LAQUETTA
Middle Name:L
Last Name:BENBOW
Suffix:
Gender:F
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 1:333 VINCELLETTE ST
Mailing Address - Street 2:UNIT # 10
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-2253
Mailing Address - Country:US
Mailing Address - Phone:203-870-8379
Mailing Address - Fax:
Practice Address - Street 1:200 NORTHPOINTE CIR
Practice Address - Street 2:STE 302
Practice Address - City:SEVEN FIELDS
Practice Address - State:PA
Practice Address - Zip Code:16046-7861
Practice Address - Country:US
Practice Address - Phone:186-674-5227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-19
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004081225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist