Provider Demographics
NPI:1598435273
Name:BENNETT, PETER JOHN JR (DPT)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:JOHN
Last Name:BENNETT
Suffix:JR
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FORKED RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08731-4654
Mailing Address - Country:US
Mailing Address - Phone:609-971-3500
Mailing Address - Fax:609-971-3545
Practice Address - Street 1:810 HOOPER AVE
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08753-7719
Practice Address - Country:US
Practice Address - Phone:732-281-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-15
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA02044500225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist