Healthcare Provider Details

I. General information

NPI: 1871404459
Provider Name (Legal Business Name): KATIE JEAN BENNETT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18806 57TH AVE NE
KENMORE WA
98028-8741
US

IV. Provider business mailing address

18806 57TH AVE NE
KENMORE WA
98028-8741
US

V. Phone/Fax

Practice location:
  • Phone: 860-970-9363
  • Fax:
Mailing address:
  • Phone: 860-970-9363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMASS.MA.70035541
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: