Provider Demographics
NPI:1396824991
Name:BENNETT, COREY DARNELL (MS, ATC, LAT, CFO)
Entity Type:Individual
Prefix:MR
First Name:COREY
Middle Name:DARNELL
Last Name:BENNETT
Suffix:
Gender:M
Credentials:MS, ATC, LAT, CFO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5079 SUMMER HAVEN WALK
Mailing Address - Street 2:
Mailing Address - City:SUGAR HILL
Mailing Address - State:GA
Mailing Address - Zip Code:30518-7997
Mailing Address - Country:US
Mailing Address - Phone:678-714-8571
Mailing Address - Fax:678-714-8571
Practice Address - Street 1:1014 SYCAMORE DR
Practice Address - Street 2:STE. B
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1644
Practice Address - Country:US
Practice Address - Phone:404-299-1700
Practice Address - Fax:404-299-1616
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0013512255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer