Provider Demographics
NPI:1104893544
Name:BENJAMIN, JOANN (PT)
Entity type:Individual
Prefix:
First Name:JOANN
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 1:4736 HALBRENT AVE
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403
Mailing Address - Country:US
Mailing Address - Phone:818-907-0971
Mailing Address - Fax:
Practice Address - Street 1:4736 HALBRENT AVE
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403
Practice Address - Country:US
Practice Address - Phone:818-907-0971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-03
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA PT15830225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT15830AMedicare ID - Type Unspecified