MEDICARE: KATHLEEN BENEVILLE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	020169-1	NY

General Provider Information

NPI Number	:	1205395969
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN BENEVILLE

Provider Business Mailing Address
First Line	:	680 STEWART AVE
Second Line	:
City	:	GARDEN CITY
State	:	NY
Zip	:	11530-4708
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	680 STEWART AVE
Second Line	:
City	:	GARDEN CITY
State	:	NY
Zip	:	11530-4708
Country	:	US
Telephone Number	:	516-398-7877
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/12/2019
Last Update Date	:	03/12/2019

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Directions to “ KATHLEEN BENEVILLE ” Practice Location

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