Provider Demographics
NPI:1396927950
Name:BENAVIDES, LAURA KATHLEEN (PT)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:KATHLEEN
Last Name:BENAVIDES
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:141 HAMPTON CIR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-4103
Mailing Address - Country:US
Mailing Address - Phone:248-853-7555
Mailing Address - Fax:248-853-7556
Practice Address - Street 1:141 HAMPTON CIR
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-4103
Practice Address - Country:US
Practice Address - Phone:248-853-7555
Practice Address - Fax:248-853-7556
Is Sole Proprietor?:No
Enumeration Date:2007-12-05
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501002903225100000X, 2251G0304X, 2251N0400X, 2251P0200X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
No2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP55360003OtherPTAN