Provider Demographics
NPI:1366830119
Name:BENNETT, TERRY
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:
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:PO BOX 125
Mailing Address - Street 2:
Mailing Address - City:HILLTOP
Mailing Address - State:WV
Mailing Address - Zip Code:25855-0125
Mailing Address - Country:US
Mailing Address - Phone:304-469-2966
Mailing Address - Fax:
Practice Address - Street 1:152 SADDLESHOP ROAD
Practice Address - Street 2:
Practice Address - City:HILLTOP
Practice Address - State:WV
Practice Address - Zip Code:25855-0125
Practice Address - Country:US
Practice Address - Phone:304-469-2966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-02
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVC1986224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant