Provider Demographics
NPI:1316956725
Name:BENTON, KELLI MICHELLE (MPT)
Entity type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:MICHELLE
Last Name:BENTON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10229 E 96TH ST N
Mailing Address - Street 2:STE 102
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-5305
Mailing Address - Country:US
Mailing Address - Phone:918-274-8541
Mailing Address - Fax:918-274-8560
Practice Address - Street 1:10229 E 96TH ST N
Practice Address - Street 2:STE 102
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-5305
Practice Address - Country:US
Practice Address - Phone:918-274-8541
Practice Address - Fax:918-274-8560
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006002907225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO578907909Medicaid
MO36557012OtherBCBS KC
266552Medicare ID - Type Unspecified