Provider Demographics
NPI:1649415712
Name:BENNER, SUSAN KAYE (MPT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:KAYE
Last Name:BENNER
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31341 NIGUEL RD
Mailing Address - Street 2:SUITE G
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-4118
Mailing Address - Country:US
Mailing Address - Phone:949-234-9720
Mailing Address - Fax:949-234-9722
Practice Address - Street 1:31341 NIGUEL RD
Practice Address - Street 2:SUITE G
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-4118
Practice Address - Country:US
Practice Address - Phone:949-234-9720
Practice Address - Fax:949-234-9722
Is Sole Proprietor?:No
Enumeration Date:2008-12-03
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23874225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist