Provider Demographics
NPI:1700516283
Name:THORNTON, BENJAMIN MICHAEL (DPT)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:MICHAEL
Last Name:THORNTON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3636 CALVERT RD APT 405
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-2679
Mailing Address - Country:US
Mailing Address - Phone:608-397-1879
Mailing Address - Fax:
Practice Address - Street 1:507 S MAIN ST
Practice Address - Street 2:
Practice Address - City:VIROQUA
Practice Address - State:WI
Practice Address - Zip Code:54665-2059
Practice Address - Country:US
Practice Address - Phone:608-637-2101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-16
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15798-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist