Provider Demographics
NPI:1316069339
Name:BENSON, GABRIELLE LAURA (LMT)
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:LAURA
Last Name:BENSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:WA
Mailing Address - Zip Code:98642-4507
Mailing Address - Country:US
Mailing Address - Phone:541-610-9429
Mailing Address - Fax:
Practice Address - Street 1:108 S MAIN AVE
Practice Address - Street 2:
Practice Address - City:RIDGEFIELD
Practice Address - State:WA
Practice Address - Zip Code:98642-3820
Practice Address - Country:US
Practice Address - Phone:541-610-9429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12400174400000X
WAMA61335708225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No174400000XOther Service ProvidersSpecialist