MEDICARE: MS. RENEE THERESE BENZINGER

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	235Z00000X	Speech-Language Pathologist	3575-154	WI

General Provider Information

NPI Number	:	1255611505
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. RENEE THERESE BENZINGER

Provider Business Mailing Address
First Line	:	510 KENTUCKY ST
Second Line	:	APT. 1
City	:	STURGEON BAY
State	:	WI
Zip	:	54235-1768
Country	:	US
Telephone Number	:	715-781-4661
Fax Number	:

Provider Business Practice Location Address
First Line	:	510 KENTUCKY ST
Second Line	:	APT. 1
City	:	STURGEON BAY
State	:	WI
Zip	:	54235-1768
Country	:	US
Telephone Number	:	715-781-4661
Fax Number	:

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

Provider Enumeration Date	:	08/18/2011
Last Update Date	:	08/18/2011

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