Provider Demographics
NPI:1942452537
Name:BENTON, AMY (PT)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:BENTON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2035 NW FRONT AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-2177
Mailing Address - Country:US
Mailing Address - Phone:503-308-1332
Mailing Address - Fax:503-850-9021
Practice Address - Street 1:2035 NW FRONT AVE FL 2
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-2177
Practice Address - Country:US
Practice Address - Phone:503-308-1332
Practice Address - Fax:503-850-9021
Is Sole Proprietor?:No
Enumeration Date:2008-10-15
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5760225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500601822Medicaid
ORP01322188OtherRR
ORR146257Medicare PIN
ORP01322188OtherRR
OR500601822Medicaid
ORR165342Medicare PIN
ORR165340Medicare PIN
ORR165913Medicare PIN