Healthcare Provider Details

I. General information

NPI: 1255667614
Provider Name (Legal Business Name): BENSON SLADE MILLER LPTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2009
Last Update Date: 06/16/2022
Certification Date: 06/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2065 GRAYSON HWY STE B
GRAYSON GA
30017-1766
US

IV. Provider business mailing address

3963 CREST LAKE DR
SOUTHSIDE AL
35907-0549
US

V. Phone/Fax

Practice location:
  • Phone: 678-376-0213
  • Fax:
Mailing address:
  • Phone: 256-485-3637
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5101
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number21588
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2073163
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA004224
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: