Provider Demographics
NPI:1710143615
Name:SEVERINO, BENJIE SIMBOLAS (PT)
Entity Type:Individual
Prefix:
First Name:BENJIE
Middle Name:SIMBOLAS
Last Name:SEVERINO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6061 N 1ST ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-5470
Mailing Address - Country:US
Mailing Address - Phone:559-435-6905
Mailing Address - Fax:
Practice Address - Street 1:6061 N 1ST ST
Practice Address - Street 2:SUITE 104
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-5470
Practice Address - Country:US
Practice Address - Phone:559-435-6905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-31
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT33983225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist