Provider Demographics
NPI:1093139560
Name:BENNETT, SHANA M (MSW, LSW)
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:M
Last Name:BENNETT
Suffix:
Gender:F
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 E GENESEE ST STE 1
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021-4045
Mailing Address - Country:US
Mailing Address - Phone:330-861-2955
Mailing Address - Fax:
Practice Address - Street 1:17 E GENESEE ST STE 1
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-4045
Practice Address - Country:US
Practice Address - Phone:330-861-2955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-04
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS 13032911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical