Provider Demographics
NPI:1366453789
Name:BENEVILLE, STEPHANIE (PT)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:BENEVILLE
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 1:4908 DORIS AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-7810
Mailing Address - Country:US
Mailing Address - Phone:704-408-9341
Mailing Address - Fax:
Practice Address - Street 1:6753 WHEELER DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-4760
Practice Address - Country:US
Practice Address - Phone:704-408-9341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP12088225100000X
NC12088225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2305204757OtherSTATE LICENSE
NCP12088OtherNORTH CAROLINA BOARD OF PT
VA012233A57Medicare ID - Type Unspecified