Provider Demographics
NPI:1487344958
Name:BENNETT, MICAH JAMES (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:MICAH
Middle Name:JAMES
Last Name:BENNETT
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 MEADOW OAKS DR
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-2377
Mailing Address - Country:US
Mailing Address - Phone:817-988-8125
Mailing Address - Fax:
Practice Address - Street 1:11801 SOUTH FWY
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-7021
Practice Address - Country:US
Practice Address - Phone:817-551-2747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13759112251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic