Provider Demographics
NPI:1679917967
Name:BENTON, URSULA (COTA)
Entity type:Individual
Prefix:
First Name:URSULA
Middle Name:
Last Name:BENTON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8220 GUNSTON COMMONS WAY
Mailing Address - Street 2:
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22079-5026
Mailing Address - Country:US
Mailing Address - Phone:254-702-0170
Mailing Address - Fax:
Practice Address - Street 1:12191 CLIPPER DR
Practice Address - Street 2:
Practice Address - City:LAKE RIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-2237
Practice Address - Country:US
Practice Address - Phone:703-496-3486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-17
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131000656224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant