Provider Demographics
NPI:1336469519
Name:BENNETT, SARAH ELISE (OTR/L)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:ELISE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:663 COLUSA AVENUE
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94707
Mailing Address - Country:US
Mailing Address - Phone:415-717-2691
Mailing Address - Fax:
Practice Address - Street 1:663 COLUSA AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94707-1517
Practice Address - Country:US
Practice Address - Phone:415-717-2691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-10
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5770174400000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No174400000XOther Service ProvidersSpecialist