Provider Demographics
NPI:1518583616
Name:BENNETT, TYLOR WAYNE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:TYLOR
Middle Name:WAYNE
Last Name:BENNETT
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4284 TRAIL BOSS DR STE 130
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80104-7521
Mailing Address - Country:US
Mailing Address - Phone:303-663-8086
Mailing Address - Fax:
Practice Address - Street 1:14400 E JEWELL AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80012-5689
Practice Address - Country:US
Practice Address - Phone:303-283-5314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-24
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO17001225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist