Provider Demographics
NPI:1710696406
Name:BENNETT, BLAKE (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12423 PLEASANT VIEW DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72212-2220
Mailing Address - Country:US
Mailing Address - Phone:501-765-6422
Mailing Address - Fax:
Practice Address - Street 1:1500 N MISSISSIPPI ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72207-5851
Practice Address - Country:US
Practice Address - Phone:501-217-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-21
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR3736225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist