Provider Demographics
NPI:1609087154
Name:BENNETT, CHERYL A (PTA)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:A
Last Name:BENNETT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 HIDDEN VALLEY CT
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60490-5537
Mailing Address - Country:US
Mailing Address - Phone:630-759-2881
Mailing Address - Fax:
Practice Address - Street 1:303 QUADRANGLE DRIVE
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440
Practice Address - Country:US
Practice Address - Phone:630-771-1070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2252100000XOtherTAXONOMY