Provider Demographics
NPI:1437605375
Name:BENNETT, AMY N (LMT, BCSI)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:N
Last Name:BENNETT
Suffix:
Gender:F
Credentials:LMT, BCSI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 NE DEKUM ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211
Mailing Address - Country:US
Mailing Address - Phone:503-781-3886
Mailing Address - Fax:
Practice Address - Street 1:510 NE DEKUM ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-2926
Practice Address - Country:US
Practice Address - Phone:503-781-3886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11023225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist