Provider Demographics
NPI:1720706468
Name:BENNETT, DEIJA
Entity Type:Individual
Prefix:
First Name:DEIJA
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 BROOKSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-4608
Mailing Address - Country:US
Mailing Address - Phone:909-805-5077
Mailing Address - Fax:
Practice Address - Street 1:312 BROOKSIDE AVE
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4608
Practice Address - Country:US
Practice Address - Phone:909-805-5077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-18
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20232225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist