MEDICARE: MRS. CRYSTAL LEE BENNETT OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	1148	NE

General Provider Information

NPI Number	:	1134312648
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CRYSTAL LEE BENNETT OTR/L

Provider Business Mailing Address
First Line	:	1240 N 19TH ST
Second Line	:
City	:	NEBRASKA CITY
State	:	NE
Zip	:	68410-1119
Country	:	US
Telephone Number	:	402-873-4838
Fax Number	:

Provider Business Practice Location Address
First Line	:	1240 N 19TH ST
Second Line	:
City	:	NEBRASKA CITY
State	:	NE
Zip	:	68410-1119
Country	:	US
Telephone Number	:	402-873-4838
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/20/2007
Last Update Date	:	08/20/2007

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