Basic Information
| Provider Information | |||||||||
| NPI: | 1174958540 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENNETT | ||||||||
| FirstName: | BRENDA | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CORBETT | ||||||||
| OtherFirstName: | BRENDA | ||||||||
| OtherMiddleName: | J | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 110 6TH AVE | ||||||||
| Address2: | |||||||||
| City: | MOUNT EPHRAIM | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080591217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8583367675 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 425 WOODBURY TURNERSVILLE RD | ||||||||
| Address2: | |||||||||
| City: | BLACKWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080122960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563746600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2013 | ||||||||
| LastUpdateDate: | 11/04/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 40QA01504900 | NJ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.