Provider Demographics
NPI:1760251276
Name:BENNETT, CLINT D
Entity Type:Individual
Prefix:
First Name:CLINT
Middle Name:D
Last Name:BENNETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 LAS COLINAS BLVD W APT 441
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75039-5475
Mailing Address - Country:US
Mailing Address - Phone:316-312-2716
Mailing Address - Fax:
Practice Address - Street 1:301 LAS COLINAS BLVD W APT 441
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75039-5475
Practice Address - Country:US
Practice Address - Phone:316-312-2716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-26
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2124679225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant