Provider Demographics
NPI:1770083446
Name:BENNETT, DOUGLAS NOLAND (DPT, CSCS)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:NOLAND
Last Name:BENNETT
Suffix:
Gender:M
Credentials:DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13525 SW ARAGON ST
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-0820
Mailing Address - Country:US
Mailing Address - Phone:971-570-6818
Mailing Address - Fax:
Practice Address - Street 1:25030 SW PARKWAY AVE STE 100
Practice Address - Street 2:
Practice Address - City:WILSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97070-9816
Practice Address - Country:US
Practice Address - Phone:503-582-1073
Practice Address - Fax:503-582-1093
Is Sole Proprietor?:No
Enumeration Date:2018-02-19
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR62607225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist