Provider Demographics
NPI:1902965387
Name:BENNETT, MARK RYAN (PT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:RYAN
Last Name:BENNETT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:658 ASHBURY ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94117-2923
Mailing Address - Country:US
Mailing Address - Phone:415-810-0504
Mailing Address - Fax:
Practice Address - Street 1:901 NEVIN AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94801-3143
Practice Address - Country:US
Practice Address - Phone:510-307-1684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33182225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist