Provider Demographics
NPI:1053851493
Name:BENNETT, ELIZABETH A (LMSW-CLINICAL)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:A
Last Name:BENNETT
Suffix:
Gender:F
Credentials:LMSW-CLINICAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 1/2 WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-3222
Mailing Address - Country:US
Mailing Address - Phone:269-303-2302
Mailing Address - Fax:269-488-5906
Practice Address - Street 1:5464 HOLIDAY TER
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-2147
Practice Address - Country:US
Practice Address - Phone:269-303-2302
Practice Address - Fax:269-488-5906
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-05
Last Update Date:2017-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801093831102L00000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst