Provider Demographics
NPI:1891853933
Name:QUIST, BENJAMIN A (DPT CSCS)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:A
Last Name:QUIST
Suffix:
Gender:M
Credentials:DPT CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8914 W BONNIWELL
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53097
Mailing Address - Country:US
Mailing Address - Phone:414-322-5750
Mailing Address - Fax:262-241-5229
Practice Address - Street 1:2020 CHEYENNE CT
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:WI
Practice Address - Zip Code:53024-0368
Practice Address - Country:US
Practice Address - Phone:262-375-1075
Practice Address - Fax:262-375-4975
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9499024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist