Provider Demographics
NPI:1548636780
Name:BENSON, MIRANDA KAY (MAT, AT, ATC)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:KAY
Last Name:BENSON
Suffix:
Gender:F
Credentials:MAT, AT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MO
Mailing Address - Zip Code:63435-1100
Mailing Address - Country:US
Mailing Address - Phone:920-639-9272
Mailing Address - Fax:
Practice Address - Street 1:1800 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-2670
Practice Address - Country:US
Practice Address - Phone:217-228-5432
Practice Address - Fax:217-228-5604
Is Sole Proprietor?:No
Enumeration Date:2015-08-11
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0046312255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer