Provider Demographics
NPI:1780795617
Name:BENJAMIN, CAROL (PT)
Entity type:Individual
Prefix:MS
First Name:CAROL
Middle Name:
Last Name:BENJAMIN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2119 WESTLAKE DR
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80503-8102
Mailing Address - Country:US
Mailing Address - Phone:303-684-9456
Mailing Address - Fax:
Practice Address - Street 1:6640 GUNPARK DR STE 102
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-7001
Practice Address - Country:US
Practice Address - Phone:303-938-3770
Practice Address - Fax:720-542-8932
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3878225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO3878OtherP T LICENSE