Provider Demographics
NPI:1073275673
Name:BENNETT, STEPHANIE MARIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MARIE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 NW 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-3609
Mailing Address - Country:US
Mailing Address - Phone:503-294-1681
Mailing Address - Fax:
Practice Address - Street 1:726 W BURNSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-3515
Practice Address - Country:US
Practice Address - Phone:503-944-4410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-11
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW3862175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist