Provider Demographics
NPI:1669740122
Name:BENDER, DEBRA DIANE (PTA)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:DIANE
Last Name:BENDER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10801 VOLINIA DR
Mailing Address - Street 2:
Mailing Address - City:OSCEOLA
Mailing Address - State:IN
Mailing Address - Zip Code:46561-9016
Mailing Address - Country:US
Mailing Address - Phone:574-674-6568
Mailing Address - Fax:
Practice Address - Street 1:700 E BEARDSLEY AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-3366
Practice Address - Country:US
Practice Address - Phone:574-206-8010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-12
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06003281A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant