Provider Demographics
NPI:1053515502
Name:BENSON, AMBER RUTH (LMT)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:RUTH
Last Name:BENSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:RUTH
Other - Last Name:WOLEVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4234 AUTUMN LN
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-8640
Mailing Address - Country:US
Mailing Address - Phone:815-232-2787
Mailing Address - Fax:
Practice Address - Street 1:206 S GALENA AVE
Practice Address - Street 2:SUITE 10
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-5174
Practice Address - Country:US
Practice Address - Phone:228-363-2812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist