Provider Demographics
NPI:1811563901
Name:BENTON, SAVANNAH L (PTA)
Entity Type:Individual
Prefix:
First Name:SAVANNAH
Middle Name:L
Last Name:BENTON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4506 SE SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27406-8685
Mailing Address - Country:US
Mailing Address - Phone:336-420-1258
Mailing Address - Fax:
Practice Address - Street 1:6100 W FRIENDLY AVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-4160
Practice Address - Country:US
Practice Address - Phone:336-292-1301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-31
Last Update Date:2021-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA7451225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant