Provider Demographics
NPI:1073158184
Name:BENNETT, SHAD W
Entity Type:Individual
Prefix:
First Name:SHAD
Middle Name:W
Last Name:BENNETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2195 W CHANDLER BLVD STE 180
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-6580
Mailing Address - Country:US
Mailing Address - Phone:809-963-9339
Mailing Address - Fax:480-963-4098
Practice Address - Street 1:2195 W CHANDLER BLVD STE 180
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224
Practice Address - Country:US
Practice Address - Phone:809-963-9339
Practice Address - Fax:480-963-4098
Is Sole Proprietor?:No
Enumeration Date:2019-11-12
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ007975225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist