MEDICARE: MRS. DANIELLE BENNETT LMT

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	225700000X	Massage Therapist	MT-27432	AZ

General Provider Information

NPI Number	:	1295615649
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DANIELLE BENNETT LMT

Provider Business Mailing Address
First Line	:	1642 MCCULLOCH BLVD N # 393
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-0961
Country	:	US
Telephone Number	:	928-706-2121
Fax Number	:

Provider Business Practice Location Address
First Line	:	1695 MESQUITE AVE STE 114
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-5687
Country	:	US
Telephone Number	:	928-453-6808
Fax Number	:	928-453-8485

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

Provider Enumeration Date	:	09/05/2025
Last Update Date	:	09/05/2025

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