Provider Demographics
NPI:1740550409
Name:BENNETT, STEPHANIE (PTL)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:PTL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:927 BROADWAY ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-2719
Mailing Address - Country:US
Mailing Address - Phone:217-222-9300
Mailing Address - Fax:217-222-9400
Practice Address - Street 1:3032 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-3708
Practice Address - Country:US
Practice Address - Phone:217-222-6800
Practice Address - Fax:217-222-0037
Is Sole Proprietor?:No
Enumeration Date:2012-01-11
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070010232225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist