Provider Demographics
NPI:1588862171
Name:BENNETT, DEBORAH J (PT)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:J
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 1:1280 N MILDRED RD STE 2
Mailing Address - Street 2:
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321-2212
Mailing Address - Country:US
Mailing Address - Phone:970-564-0311
Mailing Address - Fax:970-564-0313
Practice Address - Street 1:1280 N MILDRED RD STE 2
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-2212
Practice Address - Country:US
Practice Address - Phone:970-564-0311
Practice Address - Fax:970-564-0313
Is Sole Proprietor?:No
Enumeration Date:2007-07-05
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9067225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO48085359Medicaid
CO48085359Medicaid