Provider Demographics
NPI:1427556133
Name:BENNICI, BRIANNA MARIE
Entity Type:Individual
Prefix:MISS
First Name:BRIANNA
Middle Name:MARIE
Last Name:BENNICI
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 1:203 W LINE ST
Mailing Address - Street 2:
Mailing Address - City:OLYPHANT
Mailing Address - State:PA
Mailing Address - Zip Code:18447-2096
Mailing Address - Country:US
Mailing Address - Phone:570-472-2063
Mailing Address - Fax:
Practice Address - Street 1:45 N SCOTT ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:PA
Practice Address - Zip Code:18407
Practice Address - Country:US
Practice Address - Phone:570-282-1099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-28
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATOP009186224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant