Provider Demographics
NPI:1053833467
Name:BENNETT, ISAIAH
Entity Type:Individual
Prefix:
First Name:ISAIAH
Middle Name:
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 1:219 HAMILTON AVE APT 3E
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-1638
Mailing Address - Country:US
Mailing Address - Phone:917-755-0596
Mailing Address - Fax:
Practice Address - Street 1:19 VEDDER AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-1509
Practice Address - Country:US
Practice Address - Phone:718-370-2975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-07
Last Update Date:2017-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor