Basic Information
| Provider Information | |||||||||
| NPI: | 1306214556 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENJAMIN | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | BRANNON | ||||||||
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| Credential: | OTR L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1483 TOBIAS GADSON BLVD | ||||||||
| Address2: | STE 205B | ||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294074641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032215642 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1483 TOBIAS GADSON BLVD STE 205B | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294074641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437666494 | ||||||||
| FaxNumber: | 8437666495 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2015 | ||||||||
| LastUpdateDate: | 06/20/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XH1200X | 4579 | SC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand |
ID Information
| ID | Type | State | Issuer | Description | TH2983 | 05 | SC | MEDICAID |