Provider Demographics
NPI:1578029005
Name:BENNETT, CARLA SUE (LMT)
Entity Type:Individual
Prefix:MS
First Name:CARLA
Middle Name:SUE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
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Mailing Address - Street 1:2525 E SELTICE WAY
Mailing Address - Street 2:SUITE C
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854
Mailing Address - Country:US
Mailing Address - Phone:208-777-7463
Mailing Address - Fax:208-777-9659
Practice Address - Street 1:2525 E SELTICE WAY
Practice Address - Street 2:SUITE C
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854
Practice Address - Country:US
Practice Address - Phone:208-777-7463
Practice Address - Fax:208-777-9659
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-20
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDMAS-1743225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist