Provider Demographics
NPI:1306214556
Name:BENJAMIN, KATHLEEN BRANNON (OTR L)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:BRANNON
Last Name:BENJAMIN
Suffix:
Gender:F
Credentials:OTR L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1483 TOBIAS GADSON BLVD
Mailing Address - Street 2:STE 205B
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-4641
Mailing Address - Country:US
Mailing Address - Phone:803-221-5642
Mailing Address - Fax:
Practice Address - Street 1:1483 TOBIAS GADSON BLVD STE 205B
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-4641
Practice Address - Country:US
Practice Address - Phone:843-766-6494
Practice Address - Fax:843-766-6495
Is Sole Proprietor?:No
Enumeration Date:2015-09-04
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4579225XH1200X
225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH2983Medicaid