Healthcare Provider Details

I. General information

NPI: 1568535862
Provider Name (Legal Business Name): EDIE KNOWLTON BENNER PHD.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 09/06/2024
Certification Date: 09/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4707 MILL STREET
MANTUA OH
44255
US

IV. Provider business mailing address

PO BOX 638
MANTUA OH
44255-0638
US

V. Phone/Fax

Practice location:
  • Phone: 330-274-2747
  • Fax: 330-274-0337
Mailing address:
  • Phone: 330-274-2747
  • Fax: 330-274-0337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3343
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: