1205385879 NPI number — MRS. MICHELLE MARIE BENNETT LMT

Table of content: MRS. MICHELLE MARIE BENNETT LMT (NPI 1205385879)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205385879 NPI number — MRS. MICHELLE MARIE BENNETT LMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BENNETT
Provider First Name:
MICHELLE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LMT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205385879
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/01/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14044 CHELSEA DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE OSWGO
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97035-5760
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-515-5579
Provider Business Mailing Address Fax Number:
503-697-7810

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3689 CARMAN DR STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE OSWEGO
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97035-2620
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-515-5579
Provider Business Practice Location Address Fax Number:
503-697-7810
Provider Enumeration Date:
09/23/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225700000X , with the licence number:  21023 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com