Provider Demographics
NPI:1902441439
Name:BENNETT, LUCAS DANIEL (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:LUCAS
Middle Name:DANIEL
Last Name:BENNETT
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-3342
Mailing Address - Country:US
Mailing Address - Phone:307-857-7074
Mailing Address - Fax:307-856-6459
Practice Address - Street 1:820 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-3342
Practice Address - Country:US
Practice Address - Phone:307-857-7074
Practice Address - Fax:307-856-6459
Is Sole Proprietor?:No
Enumeration Date:2019-11-07
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044522225100000X
WYPT1932225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYPT1932OtherSTATE ISSUED PHYSICAL THERAPY LICENSE