Provider Demographics
NPI:1871290023
Name:BENEFIELD, RAEGAN
Entity type:Individual
Prefix:
First Name:RAEGAN
Middle Name:
Last Name:BENEFIELD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42168 BALD EAGLE AVE
Mailing Address - Street 2:
Mailing Address - City:PRAIRIEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70769-6065
Mailing Address - Country:US
Mailing Address - Phone:225-413-4308
Mailing Address - Fax:
Practice Address - Street 1:210 W HIGHWAY 30 # 201
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-4818
Practice Address - Country:US
Practice Address - Phone:225-413-4308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-08
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA7272225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist