Provider Demographics
NPI:1902994114
Name:OTIS, BENJAMIN N (MSPT)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:N
Last Name:OTIS
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 MCNABB CT
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-4431
Mailing Address - Country:US
Mailing Address - Phone:603-812-5616
Mailing Address - Fax:
Practice Address - Street 1:230 LAFAYETTE RD STE 10
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-5429
Practice Address - Country:US
Practice Address - Phone:603-812-3300
Practice Address - Fax:603-420-7554
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH3097225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist