Provider Demographics
NPI:1740632215
Name:POWLEY, BENTON TODD (PTA)
Entity type:Individual
Prefix:
First Name:BENTON
Middle Name:TODD
Last Name:POWLEY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8118 LARIAT DR
Mailing Address - Street 2:
Mailing Address - City:SUMMERFIELD
Mailing Address - State:NC
Mailing Address - Zip Code:27358-9757
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8118 LARIAT DR
Practice Address - Street 2:
Practice Address - City:SUMMERFIELD
Practice Address - State:NC
Practice Address - Zip Code:27358-9757
Practice Address - Country:US
Practice Address - Phone:336-772-3910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-08
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2119080225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant