Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | PU 60159680 | WA |
N | 2251S0007X | Physical Therapist - Sports | PU 60159680 | WA |
NPI | 1447570809 |
---|---|
Provider Name | Dr. Brandon Bruce Bennett |
First Address | Lacey, WA 98503-4804 |
Second Address | Lacey, WA 98503-4804 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 08/06/2010 |
Last Update Date | 28/01/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
A1 60054681 | ATHLETIC TRAINER LICENSE (01) | WA |
PU 60159680 | PHYSICAL THERAPIST INTERIM PERMIT (01) | WA |