Healthcare Provider Details

I. General information

NPI: 1336469519
Provider Name (Legal Business Name): SARAH ELISE BENNETT OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2010
Last Update Date: 06/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

663 COLUSA AVE
BERKELEY CA
94707-1517
US

IV. Provider business mailing address

663 COLUSA AVENUE
BERKELEY CA
94707
US

V. Phone/Fax

Practice location:
  • Phone: 415-717-2691
  • Fax:
Mailing address:
  • Phone: 415-717-2691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number5770
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number5770
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: