Provider Demographics
NPI:1770290041
Name:BENNETT, TABITHA (PT, DPT)
Entity type:Individual
Prefix:
First Name:TABITHA
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:TABITHA
Other - Middle Name:
Other - Last Name:SHERK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:625 KENMOOR AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:245 CHERRY ST SE STE 102
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4607
Practice Address - Country:US
Practice Address - Phone:269-948-7489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-04
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501302178225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist