Basic Information
| Provider Information | |||||||||
| NPI: | 1659679801 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENCIVENGA | ||||||||
| FirstName: | MARIO | ||||||||
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| Credential: | OTR/L, CHT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 BREWSTER BLVD | ||||||||
| Address2: | |||||||||
| City: | CAMP LEJEUNE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285472575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104504750 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 100 BREWSTER BLVD | ||||||||
| Address2: | |||||||||
| City: | CAMP LEJEUNE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285472575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104504750 | ||||||||
| FaxNumber: | 9104503406 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2011 | ||||||||
| LastUpdateDate: | 03/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225XP0019X | 3790 | CT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Physical Rehabilitation |
No ID Information.