Provider Demographics
NPI:1841944154
Name:BENNETT, AUDREY (OTR/L)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2122 YORK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1925
Mailing Address - Country:US
Mailing Address - Phone:630-575-1980
Mailing Address - Fax:
Practice Address - Street 1:1595 W LAKE LANSING RD STE 130
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-1317
Practice Address - Country:US
Practice Address - Phone:517-333-6692
Practice Address - Fax:517-333-6705
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-05
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12642934-4201225X00000X
MI5201012735225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist