Provider Demographics
NPI:1881907566
Name:BENNETT, CRYSTAL YVETTE (LMP)
Entity type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:YVETTE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:MRS
Other - First Name:CRYSTAL
Other - Middle Name:YVETTE
Other - Last Name:OLSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMP
Mailing Address - Street 1:37 103RD AVE NE STE A
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-4983
Mailing Address - Country:US
Mailing Address - Phone:425-451-1171
Mailing Address - Fax:
Practice Address - Street 1:37 103RD AVE NE STE A
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-4983
Practice Address - Country:US
Practice Address - Phone:425-451-1171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-22
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60084404225700000X
AZMT-09920225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist