Provider Demographics
NPI:1285094623
Name:BENITEZ, BRIANA ELAN (COTA)
Entity type:Individual
Prefix:
First Name:BRIANA
Middle Name:ELAN
Last Name:BENITEZ
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4132 148TH ST
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:IL
Mailing Address - Zip Code:60445-3306
Mailing Address - Country:US
Mailing Address - Phone:708-224-6381
Mailing Address - Fax:
Practice Address - Street 1:4132 148TH ST
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:IL
Practice Address - Zip Code:60445-3306
Practice Address - Country:US
Practice Address - Phone:708-224-6381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-27
Last Update Date:2016-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057004056224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant