Provider Demographics
NPI:1215155049
Name:BENNY, GWYN L (PT)
Entity type:Individual
Prefix:
First Name:GWYN
Middle Name:L
Last Name:BENNY
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 1:949 MOUNT HERMON RD
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-5105
Mailing Address - Country:US
Mailing Address - Phone:410-543-9000
Mailing Address - Fax:410-543-9033
Practice Address - Street 1:949 MOUNT HERMON RD
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-5105
Practice Address - Country:US
Practice Address - Phone:410-543-9000
Practice Address - Fax:410-543-9033
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15756225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD071378301Medicaid
MD44002OtherMAMSI
MD52788201OtherCAREFIRST
MDS4020003OtherFED BCBS
MD44002OtherMAMSI