Healthcare Provider Details

I. General information

NPI: 1558415406
Provider Name (Legal Business Name): VALENCIA BENTON HENSON LPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 AVIGNON DR
RIDGELAND MS
39157-5120
US

IV. Provider business mailing address

326 DELTA DR W
HATTIESBURG MS
39402-8344
US

V. Phone/Fax

Practice location:
  • Phone: 601-605-6777
  • Fax: 601-605-8869
Mailing address:
  • Phone: 601-579-9295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA2037
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: