Provider Demographics
NPI:1477008340
Name:BENNER, COURTNEY LYNNE (MOT, OTR/L, RBT)
Entity Type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:LYNNE
Last Name:BENNER
Suffix:
Gender:F
Credentials:MOT, OTR/L, RBT
Other - Prefix:MISS
Other - First Name:COURTNEY
Other - Middle Name:LYNNE
Other - Last Name:SCHAFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MOT, OTR/L, RBT
Mailing Address - Street 1:875 SOUTH 700 EAST
Mailing Address - Street 2:APT 105
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84097
Mailing Address - Country:US
Mailing Address - Phone:307-438-1768
Mailing Address - Fax:
Practice Address - Street 1:875 SOUTH 700 EAST
Practice Address - Street 2:APT 105
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84097
Practice Address - Country:US
Practice Address - Phone:307-438-1768
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-22
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTRBT-19-80902106S00000X
UT9834370-4201225XM0800X, 225XP0200X, 225X00000X
225XM0800X
IDOT-1654225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No225XM0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistMental Health
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT3008546Medicaid
ID225X00000XMedicaid