Provider Demographics
NPI:1063550002
Name:BENTSEN, KELLI DONAHUE
Entity type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:DONAHUE
Last Name:BENTSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 BROOKS BAY DR
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-5706
Mailing Address - Country:US
Mailing Address - Phone:252-213-0001
Mailing Address - Fax:919-693-9381
Practice Address - Street 1:1010 BROOKS BAY DR
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16505-5706
Practice Address - Country:US
Practice Address - Phone:252-213-0001
Practice Address - Fax:919-693-9381
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT023939225100000X
NC87532251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC078K3OtherBCBS IND #
NC7211010Medicaid