Provider Demographics
NPI:1265075972
Name:PARADISE, BENJAMIN LEE (COTA/L)
Entity type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:LEE
Last Name:PARADISE
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7182 S 1200 E
Mailing Address - Street 2:
Mailing Address - City:SOUTH WEBER
Mailing Address - State:UT
Mailing Address - Zip Code:84405-9479
Mailing Address - Country:US
Mailing Address - Phone:801-636-8515
Mailing Address - Fax:
Practice Address - Street 1:802 W 3RD AVE
Practice Address - Street 2:
Practice Address - City:TOPPENISH
Practice Address - State:WA
Practice Address - Zip Code:98948-1668
Practice Address - Country:US
Practice Address - Phone:509-865-3955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-25
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5692129-4202224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant