Provider Demographics
NPI:1366927758
Name:BENNETT, CASSANDRA LESLIE ELAINE (OTRL)
Entity type:Individual
Prefix:MS
First Name:CASSANDRA
Middle Name:LESLIE ELAINE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:MRS
Other - First Name:CASSANDRA
Other - Middle Name:L
Other - Last Name:WEDDINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:18193 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:MI
Mailing Address - Zip Code:49095-9701
Mailing Address - Country:US
Mailing Address - Phone:269-591-2497
Mailing Address - Fax:
Practice Address - Street 1:18193 W STATE ST
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:MI
Practice Address - Zip Code:49095-9701
Practice Address - Country:US
Practice Address - Phone:269-591-2497
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-01
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201008994225X00000X
IN31006588A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist