Provider Demographics
NPI:1245323732
Name:BENEDYK, COREY LEIGH (OTR)
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:LEIGH
Last Name:BENEDYK
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:COREY
Other - Middle Name:L
Other - Last Name:CHADWICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10790 RANCHO BERNARDO RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-5705
Mailing Address - Country:US
Mailing Address - Phone:858-554-8852
Mailing Address - Fax:
Practice Address - Street 1:10666 N TORREY PINES RD
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1027
Practice Address - Country:US
Practice Address - Phone:858-554-8852
Practice Address - Fax:858-554-6321
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT 17081225X00000X
MO2015033924225X00000X
IN31003895A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200449300Medicaid
IN062110I6Medicare PIN
INP01271413Medicare PIN
IN156524Medicare PIN
IN815500036Medicare PIN
IN000000667696OtherANTHEM PROVIDER NUMBER / ARNETT CLINIC, LLC
IN200449300Medicaid