Provider Demographics
NPI:1104153360
Name:BENNETT, CRISTIE (PT)
Entity type:Individual
Prefix:
First Name:CRISTIE
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 WALKER RD
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-1682
Mailing Address - Country:US
Mailing Address - Phone:530-400-8532
Mailing Address - Fax:
Practice Address - Street 1:165 ROWLAND WAY
Practice Address - Street 2:STE. 101
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94945-5038
Practice Address - Country:US
Practice Address - Phone:415-898-1311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-09
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36186208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation