Provider Demographics
NPI:1518104611
Name:BENNETT, ALAN D (LMP)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:D
Last Name:BENNETT
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 S 7TH ST
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-2710
Mailing Address - Country:US
Mailing Address - Phone:360-432-7834
Mailing Address - Fax:
Practice Address - Street 1:1208 S 7TH ST
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-2710
Practice Address - Country:US
Practice Address - Phone:360-432-7834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-12
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00007761225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA00007761OtherWA STATE MASSAGE LICENSE #