Basic Information
| Provider Information | |||||||||
| NPI: | 1912140476 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENSON | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MOT, OTR/L, CHT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | EASTON | ||||||||
| OtherFirstName: | TRACY | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | OT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962223 | ||||||||
| FaxNumber: | 6307599510 | ||||||||
| Practice Location | |||||||||
| Address1: | 7224 118TH AVE | ||||||||
| Address2: | STE E | ||||||||
| City: | KENOSHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531428424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2628574400 | ||||||||
| FaxNumber: | 2628574411 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2009 | ||||||||
| LastUpdateDate: | 01/08/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 056.007462 | IL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | WI5346-26 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.