Provider Demographics
NPI:1538301486
Name:BENNETT, LORI (PT)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 COURSEVALL DRIVE
Mailing Address - Street 2:SUITE 111 & 112
Mailing Address - City:CENTREVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21617
Mailing Address - Country:US
Mailing Address - Phone:410-758-0018
Mailing Address - Fax:
Practice Address - Street 1:3179 BRAVERTON STREET
Practice Address - Street 2:SUITE 201
Practice Address - City:EDGEWATER
Practice Address - State:MD
Practice Address - Zip Code:21037
Practice Address - Country:US
Practice Address - Phone:410-956-4308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-24
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16050225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist