Provider Demographics
NPI:1942452537
Name:BENTON, AMY (PT)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:BENTON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16083 SW UPPER BOONES FERRY RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7736
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-639-9699
Practice Address - Street 1:4415 SW VERMONT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-1020
Practice Address - Country:US
Practice Address - Phone:503-244-0570
Practice Address - Fax:503-244-0572
Is Sole Proprietor?:No
Enumeration Date:2008-10-15
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5760225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500601822Medicaid
ORP01322188OtherRR
ORR146257Medicare PIN
ORP01322188OtherRR
OR500601822Medicaid
ORR165342Medicare PIN
ORR165340Medicare PIN
ORR165913Medicare PIN