Provider Demographics
NPI:1871668939
Name:BENNETT, LORI L (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:MISS
First Name:LORI
Middle Name:L
Last Name:BENNETT
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:522 HERMOSA DR SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108
Mailing Address - Country:US
Mailing Address - Phone:505-268-9209
Mailing Address - Fax:
Practice Address - Street 1:7920 MOUNTAIN RD NE
Practice Address - Street 2:ALBUQUERQUE PHYSICAL THERAPISTS
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-7805
Practice Address - Country:US
Practice Address - Phone:505-888-7979
Practice Address - Fax:505-888-8859
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM705225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00Q017OtherBCBS
700521007Medicare ID - Type UnspecifiedGRP