Provider Demographics
NPI:1649715145
Name:BENNETT, MICHELLE (LMT#8540,CNMT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:LMT#8540,CNMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4610 EUBANK BLVD NE
Mailing Address - Street 2:APT 103
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-2553
Mailing Address - Country:US
Mailing Address - Phone:505-206-7180
Mailing Address - Fax:
Practice Address - Street 1:6303 INDIAN SCHOOL RD NE
Practice Address - Street 2:SUITE 102B
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-5328
Practice Address - Country:US
Practice Address - Phone:505-582-1176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-20
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM8540225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist