Provider Demographics
NPI:1932403003
Name:WILSON, BENJAMIN DOUGLES (MPT)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:DOUGLES
Last Name:WILSON
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11320 INDUSTRIPLEX BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-4108
Mailing Address - Country:US
Mailing Address - Phone:225-663-8238
Mailing Address - Fax:
Practice Address - Street 1:850 N PIERCE ST
Practice Address - Street 2:SUITE A
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70501-2848
Practice Address - Country:US
Practice Address - Phone:337-261-9100
Practice Address - Fax:337-261-9700
Is Sole Proprietor?:No
Enumeration Date:2011-01-05
Last Update Date:2017-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA06674225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist