Provider Demographics
NPI:1235808387
Name:BENNETT, MARK A
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:BENNETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 BRIARWOOD PL
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27332-2382
Mailing Address - Country:US
Mailing Address - Phone:270-307-3393
Mailing Address - Fax:
Practice Address - Street 1:801 PINEHURST AVE
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:NC
Practice Address - Zip Code:28327-9338
Practice Address - Country:US
Practice Address - Phone:910-947-5155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-12
Last Update Date:2021-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12664225XG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology