Provider Demographics
NPI:1447570809
Name:BENNETT, BRANDON BRUCE (DPT, LAT)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:BRUCE
Last Name:BENNETT
Suffix:
Gender:M
Credentials:DPT, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7605 38TH CT SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-4804
Mailing Address - Country:US
Mailing Address - Phone:360-349-8606
Mailing Address - Fax:
Practice Address - Street 1:7605 38TH CT SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-4804
Practice Address - Country:US
Practice Address - Phone:360-349-8606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-08
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPU 601596802251S0007X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPU 60159680OtherPHYSICAL THERAPIST INTERIM PERMIT
WAA1 60054681OtherATHLETIC TRAINER LICENSE