Healthcare Provider Details

I. General information

NPI: 1497282529
Provider Name (Legal Business Name): MATTHEW LEE BENNETT DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3915 GOLDEN VALLEY RD
MINNEAPOLIS MN
55422-4249
US

IV. Provider business mailing address

10845 69TH AVE N
MAPLE GROVE MN
55369-5520
US

V. Phone/Fax

Practice location:
  • Phone: 612-775-2499
  • Fax:
Mailing address:
  • Phone: 763-370-9081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: