Provider Demographics
NPI:1972978542
Name:FENISON, BENJAMIN (MOTR)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:FENISON
Suffix:
Gender:M
Credentials:MOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 12TH AVE W STE 2A
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59912-3855
Mailing Address - Country:US
Mailing Address - Phone:406-471-9910
Mailing Address - Fax:406-309-2076
Practice Address - Street 1:1035 US HIGHWAY 2 W
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3407
Practice Address - Country:US
Practice Address - Phone:406-471-9910
Practice Address - Fax:406-309-2076
Is Sole Proprietor?:No
Enumeration Date:2015-12-08
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60468807225X00000X
MT8563225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist