Provider Demographics
NPI:1649680208
Name:BENJAMIN, SUZANNE (ATC)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:BENJAMIN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 S COLUMBIA RD
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4012
Mailing Address - Country:US
Mailing Address - Phone:701-780-6771
Mailing Address - Fax:701-780-6088
Practice Address - Street 1:1300 S COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4012
Practice Address - Country:US
Practice Address - Phone:701-780-6771
Practice Address - Fax:701-780-6088
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-05
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND20162255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer