Provider Demographics
NPI:1356671507
Name:BENNETT, ROCKWELL GREY SUNCUACO (PT)
Entity Type:Individual
Prefix:
First Name:ROCKWELL GREY
Middle Name:SUNCUACO
Last Name:BENNETT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2129 25TH RD
Mailing Address - Street 2:APT. 2
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11102-3425
Mailing Address - Country:US
Mailing Address - Phone:917-388-5059
Mailing Address - Fax:
Practice Address - Street 1:2129 25TH RD
Practice Address - Street 2:APT. 2
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11102-3425
Practice Address - Country:US
Practice Address - Phone:917-388-5059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-12
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030819225100000X
IL070.017489225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist