Provider Demographics
NPI:1417944547
Name:BENNETT, VANESSA R (PT)
Entity type:Individual
Prefix:MS
First Name:VANESSA
Middle Name:R
Last Name:BENNETT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:VANESSA
Other - Middle Name:REED
Other - Last Name:PRIVITERA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:10 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:ELKINS
Mailing Address - State:WV
Mailing Address - Zip Code:26241
Mailing Address - Country:US
Mailing Address - Phone:304-636-1548
Mailing Address - Fax:304-636-1566
Practice Address - Street 1:10 MAIN STREET
Practice Address - Street 2:
Practice Address - City:ELKINS
Practice Address - State:WV
Practice Address - Zip Code:26241
Practice Address - Country:US
Practice Address - Phone:304-636-1548
Practice Address - Fax:304-636-1566
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21341225100000X
VA2305204519225100000X
WV002709225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
018980C95Medicare PIN
538695Medicare PIN
WV4277141Medicare UPIN
WVY277141Medicare UPIN
MD406634100Medicare ID - Type UnspecifiedMARYLAND MEDICAID #