Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | PT023939 | PA |
N | 2251P0200X | Physical Therapist - Pediatrics | 8753 | NC |
NPI | 1063550002 |
---|---|
Provider Name | Mrs. Kelli Donahue Bentsen |
First Address | Erie, PA 16505-5706 |
Second Address | Erie, PA 16505-5706 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/02/2007 |
Last Update Date | 23/07/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
078K3 | BCBS IND # (01) | NC |
7211010 | (05) | NC |