Healthcare Provider Details

I. General information

NPI: 1851532873
Provider Name (Legal Business Name): BENJIE RUSSELL PEASE MOT OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2009
Last Update Date: 09/09/2020
Certification Date: 09/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1830 BICKFORD AVE SUITE 209
SNOHOMISH WA
98290-1749
US

IV. Provider business mailing address

330 FRANKLIN RD STE 135A-102
BRENTWOOD TN
37027-3280
US

V. Phone/Fax

Practice location:
  • Phone: 360-568-7774
  • Fax: 360-568-7779
Mailing address:
  • Phone: 760-256-2800
  • Fax: 760-256-2809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number60078673
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License NumberOT60078673
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: