Provider Demographics
NPI:1417589375
Name:BENNETT, ERIN L
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:L
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 25231
Mailing Address - Street 2:
Mailing Address - City:MUNDS PARK
Mailing Address - State:AZ
Mailing Address - Zip Code:86017-5231
Mailing Address - Country:US
Mailing Address - Phone:480-247-0901
Mailing Address - Fax:
Practice Address - Street 1:1298 W FINNIE FLAT RD
Practice Address - Street 2:
Practice Address - City:CAMP VERDE
Practice Address - State:AZ
Practice Address - Zip Code:86322-5958
Practice Address - Country:US
Practice Address - Phone:986-395-5625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-09
Last Update Date:2020-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30459261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy