Provider Demographics
NPI:1518313220
Name:BENNETT, SUSAN (HIS)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1746 W 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-3710
Mailing Address - Country:US
Mailing Address - Phone:541-342-7678
Mailing Address - Fax:541-342-7223
Practice Address - Street 1:5466 RIVER RD N
Practice Address - Street 2:
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-4483
Practice Address - Country:US
Practice Address - Phone:503-393-2222
Practice Address - Fax:502-393-2723
Is Sole Proprietor?:No
Enumeration Date:2016-05-11
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10170701237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist