Provider Demographics
NPI:1518057744
Name:BENNETT, SUSAN LEAH (DC)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:LEAH
Last Name:BENNETT
Suffix:
Gender:F
Credentials:DC
Other - Prefix:MRS
Other - First Name:SUSAN
Other - Middle Name:LEAH
Other - Last Name:HERBST
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:PO BOX 788
Mailing Address - Street 2:
Mailing Address - City:OLEAN
Mailing Address - State:NY
Mailing Address - Zip Code:14760
Mailing Address - Country:US
Mailing Address - Phone:716-373-1197
Mailing Address - Fax:716-372-4045
Practice Address - Street 1:121 N UNION ST
Practice Address - Street 2:
Practice Address - City:OLEAN
Practice Address - State:NY
Practice Address - Zip Code:14760
Practice Address - Country:US
Practice Address - Phone:716-373-1197
Practice Address - Fax:716-372-4045
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX0023181111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYDC226028OtherWC
T26066Medicare UPIN
NYDC226028OtherWC