Provider Demographics
NPI:1750745352
Name:BENNETT, SUSAN MARIE (COTA/L)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:MARIE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2214 S ESTELLE ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67211-5505
Mailing Address - Country:US
Mailing Address - Phone:316-303-2595
Mailing Address - Fax:
Practice Address - Street 1:200 W CEDAR ST
Practice Address - Street 2:
Practice Address - City:HESSTON
Practice Address - State:KS
Practice Address - Zip Code:67062-8100
Practice Address - Country:US
Practice Address - Phone:620-327-0400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-09
Last Update Date:2016-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS18-00139224Z00000X, 224ZE0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No224ZE0001XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantEnvironmental Modification