Provider Demographics
NPI:1194197806
Name:BENSON, TANNER
Entity type:Individual
Prefix:
First Name:TANNER
Middle Name:
Last Name:BENSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 SAUK CT
Mailing Address - Street 2:
Mailing Address - City:SPARLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61565-9409
Mailing Address - Country:US
Mailing Address - Phone:309-371-5350
Mailing Address - Fax:
Practice Address - Street 1:36 SAUK CT
Practice Address - Street 2:
Practice Address - City:SPARLAND
Practice Address - State:IL
Practice Address - Zip Code:61565-9409
Practice Address - Country:US
Practice Address - Phone:309-371-5350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-21
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPT-2024-0345225100000X
TX2116126225200000X
IL160006710225200000X
IL070025342225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant