Healthcare Provider Details

I. General information

NPI: 1053580399
Provider Name (Legal Business Name): MARY LOUISE BENNETT P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2008
Last Update Date: 02/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5908 MONROE AVE
EVANSVILLE IN
47715-5052
US

IV. Provider business mailing address

5908 MONROE AVE
EVANSVILLE IN
47715-5052
US

V. Phone/Fax

Practice location:
  • Phone: 812-477-5761
  • Fax:
Mailing address:
  • Phone: 812-477-5761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number05000616A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: