Provider Demographics
NPI:1316552334
Name:BENNETT, RAENA (LMT)
Entity Type:Individual
Prefix:
First Name:RAENA
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1314
Mailing Address - Street 2:
Mailing Address - City:LAKE STEVENS
Mailing Address - State:WA
Mailing Address - Zip Code:98258-1314
Mailing Address - Country:US
Mailing Address - Phone:425-293-4756
Mailing Address - Fax:
Practice Address - Street 1:1904 125TH AVE NE
Practice Address - Street 2:
Practice Address - City:LAKE STEVENS
Practice Address - State:WA
Practice Address - Zip Code:98258-9628
Practice Address - Country:US
Practice Address - Phone:425-293-4756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-15
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61090940225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist