Provider Demographics
NPI:1720542608
Name:ROBERTS, BENJAMIN
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:183 S ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:COCHRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:16314-8605
Mailing Address - Country:US
Mailing Address - Phone:814-758-7322
Mailing Address - Fax:
Practice Address - Street 1:183 S ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:COCHRANTON
Practice Address - State:PA
Practice Address - Zip Code:16314-8605
Practice Address - Country:US
Practice Address - Phone:814-758-7322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-25
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA2255A2300X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer