Provider Demographics
NPI:1982175220
Name:BENNETT, PENNY LORI (COTA)
Entity Type:Individual
Prefix:MRS
First Name:PENNY
Middle Name:LORI
Last Name:BENNETT
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 DEVELOPMENT BLVD
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76705-2903
Mailing Address - Country:US
Mailing Address - Phone:512-799-7339
Mailing Address - Fax:
Practice Address - Street 1:2401 DEVELOPMENT BLVD
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76705-2903
Practice Address - Country:US
Practice Address - Phone:512-799-7339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX211418224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNO IDENTIFIER NO AVAILABLE