Provider Demographics
NPI:1336417484
Name:BENNINGTON, HEATHER RAE (ATC, PT)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:RAE
Last Name:BENNINGTON
Suffix:
Gender:F
Credentials:ATC, PT
Other - Prefix:MISS
Other - First Name:HEATHER
Other - Middle Name:RAE
Other - Last Name:RISOVI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3838 12TH AVE N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-2931
Mailing Address - Country:US
Mailing Address - Phone:701-234-4703
Mailing Address - Fax:
Practice Address - Street 1:3838 12TH AVE N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-2931
Practice Address - Country:US
Practice Address - Phone:701-234-4703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-05
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1321225100000X
MN6950225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist