Provider Demographics
NPI:1629037999
Name:BENNETT, ALICIA MARIE (MS, ATC, CPFS)
Entity Type:Individual
Prefix:MS
First Name:ALICIA
Middle Name:MARIE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:MS, ATC, CPFS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 LAMA ST.
Mailing Address - Street 2:
Mailing Address - City:LANAI CITY
Mailing Address - State:HI
Mailing Address - Zip Code:96763-0630
Mailing Address - Country:US
Mailing Address - Phone:808-559-6435
Mailing Address - Fax:
Practice Address - Street 1:340 LAMA ST.
Practice Address - Street 2:
Practice Address - City:LANAI CITY
Practice Address - State:HI
Practice Address - Zip Code:96763-0630
Practice Address - Country:US
Practice Address - Phone:808-559-6435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer