MEDICARE: DONNA BENNETT

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	235Z00000X	Speech-Language Pathologist	SLPS4106	AZ

General Provider Information

NPI Number	:	1689728222
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONNA BENNETT

Provider Business Mailing Address
First Line	:	PO BOX 5070
Second Line	:
City	:	MOHAVE VALLEY
State	:	AZ
Zip	:	86446-5070
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1760 JOY LN
Second Line	:
City	:	FORT MOHAVE
State	:	AZ
Zip	:	86426-9294
Country	:	US
Telephone Number	:	928-768-3986
Fax Number	:	928-768-8075

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

Provider Enumeration Date	:	01/22/2007
Last Update Date	:	07/08/2007

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Directions to “ DONNA BENNETT ” Practice Location

Language	Start Address	Practice Location

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