Provider Demographics
NPI:1154873891
Name:BENNETT, CHAISE A (PT)
Entity type:Individual
Prefix:
First Name:CHAISE
Middle Name:A
Last Name:BENNETT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2040 GAUSE BLVD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461
Mailing Address - Country:US
Mailing Address - Phone:985-646-2440
Mailing Address - Fax:877-545-9491
Practice Address - Street 1:2040 GAUSE BLVD
Practice Address - Street 2:SUITE 6
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461
Practice Address - Country:US
Practice Address - Phone:985-646-2440
Practice Address - Fax:877-545-9491
Is Sole Proprietor?:No
Enumeration Date:2016-10-28
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA08837R225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist