Provider Demographics
NPI:1073860474
Name:BENNETT, DEMETRIA L (MA)
Entity Type:Individual
Prefix:MRS
First Name:DEMETRIA
Middle Name:L
Last Name:BENNETT
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MRS
Other - First Name:DEMETRIA
Other - Middle Name:L
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:516 S CREYTS RD
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-8268
Mailing Address - Country:US
Mailing Address - Phone:517-323-1767
Mailing Address - Fax:
Practice Address - Street 1:516 S. CREYTS RD, SUITE F
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-8268
Practice Address - Country:US
Practice Address - Phone:517-323-1767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-06
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
MI4101006641106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)