Provider Demographics
NPI:1043323009
Name:BENNETT, LUCILLE L (PT)
Entity Type:Individual
Prefix:
First Name:LUCILLE
Middle Name:L
Last Name:BENNETT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 SESAME ST STE 101
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-6647
Mailing Address - Country:US
Mailing Address - Phone:907-561-2260
Mailing Address - Fax:907-561-0448
Practice Address - Street 1:701 SESAME ST STE 101
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-6647
Practice Address - Country:US
Practice Address - Phone:907-561-2260
Practice Address - Fax:907-561-0448
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAA715225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKPT45371Medicaid
AKPT45371Medicaid