Provider Demographics
NPI:1235262932
Name:BENNETT, LAUREL KAYE (PT)
Entity Type:Individual
Prefix:
First Name:LAUREL
Middle Name:KAYE
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 1:1685 W 2200 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-1456
Mailing Address - Country:US
Mailing Address - Phone:801-887-5455
Mailing Address - Fax:801-972-1384
Practice Address - Street 1:1685 W 2200 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84119-1456
Practice Address - Country:US
Practice Address - Phone:801-887-5455
Practice Address - Fax:801-972-1384
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT366380-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist