Provider Demographics
NPI:1144272550
Name:BENTON, DIANA THERESIA (MPT)
Entity type:Individual
Prefix:MS
First Name:DIANA
Middle Name:THERESIA
Last Name:BENTON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 GRAND CENTRAL AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:VIENNA
Mailing Address - State:WV
Mailing Address - Zip Code:26105-1079
Mailing Address - Country:US
Mailing Address - Phone:304-295-3060
Mailing Address - Fax:
Practice Address - Street 1:1500 GRAND CENTRAL AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:VIENNA
Practice Address - State:WV
Practice Address - Zip Code:26105-1079
Practice Address - Country:US
Practice Address - Phone:304-295-3060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH11381225100000X
WV002557225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4180901Medicare ID - Type Unspecified
WV4180911Medicare ID - Type Unspecified