Provider Demographics
NPI:1871739631
Name:BENSON, POLLY ELLEN (OTR/L)
Entity type:Individual
Prefix:
First Name:POLLY
Middle Name:ELLEN
Last Name:BENSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6170 MASTERS CLUB DR
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-3418
Mailing Address - Country:US
Mailing Address - Phone:614-579-1142
Mailing Address - Fax:614-414-0280
Practice Address - Street 1:170 MILL ST
Practice Address - Street 2:
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230-3036
Practice Address - Country:US
Practice Address - Phone:614-414-5437
Practice Address - Fax:614-414-0280
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-29
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT-005125225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation