Provider Demographics
NPI:1134158538
Name:BENNETT, MARY W (ATC, LAT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:W
Last Name:BENNETT
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 LOOP RD
Mailing Address - Street 2:APT 2D
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-8535
Mailing Address - Country:US
Mailing Address - Phone:912-277-2035
Mailing Address - Fax:
Practice Address - Street 1:101 HARRIS INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8845
Practice Address - Country:US
Practice Address - Phone:912-277-2035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0012492255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer