Provider Demographics
NPI:1205911872
Name:BENNETT, STEVEN CLARK (MSPT)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:CLARK
Last Name:BENNETT
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 N 200 E
Mailing Address - Street 2:#3E
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-3010
Mailing Address - Country:US
Mailing Address - Phone:435-628-5194
Mailing Address - Fax:435-628-5194
Practice Address - Street 1:301 N 200 E
Practice Address - Street 2:#3E
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-3010
Practice Address - Country:US
Practice Address - Phone:435-628-5194
Practice Address - Fax:435-628-5194
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT354321-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTS81616Medicare UPIN