Provider Demographics
NPI:1568008902
Name:BENSON, TRACI
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:BENSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8936 SPANISH RIDGE AVE
Mailing Address - Street 2:CREDENTIALING
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148
Mailing Address - Country:US
Mailing Address - Phone:702-998-2816
Mailing Address - Fax:702-998-2991
Practice Address - Street 1:3940 N MARTIN LUTHER KING BLVD
Practice Address - Street 2:SUITE 105B
Practice Address - City:N LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032
Practice Address - Country:US
Practice Address - Phone:702-731-0909
Practice Address - Fax:702-724-1978
Is Sole Proprietor?:No
Enumeration Date:2019-11-20
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner