Provider Demographics
NPI:1871860197
Name:BENEDICT, KATIE LOUISE
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:LOUISE
Last Name:BENEDICT
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 1:2916 38TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-5665
Mailing Address - Country:US
Mailing Address - Phone:410-459-3485
Mailing Address - Fax:
Practice Address - Street 1:2916 38TH ST
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-5665
Practice Address - Country:US
Practice Address - Phone:410-459-3485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-01
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist