Provider Demographics
NPI:1962288993
Name:BENTON, SHAWN DAVID (PTA)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:DAVID
Last Name:BENTON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1737 CITRUS HILL LN
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34683-3908
Mailing Address - Country:US
Mailing Address - Phone:727-291-3073
Mailing Address - Fax:
Practice Address - Street 1:1737 CITRUS HILL LN
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34683-3908
Practice Address - Country:US
Practice Address - Phone:727-291-3073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-06
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL28650225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant