Provider Demographics
NPI:1093824294
Name:BENNETT, AUDREY L (LCSW, LADC)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:L
Last Name:BENNETT
Suffix:
Gender:F
Credentials:LCSW, LADC
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:L
Other - Last Name:SCOVILLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:95-1184 MAKAIKAI ST APT 55
Mailing Address - Street 2:
Mailing Address - City:MILILANI
Mailing Address - State:HI
Mailing Address - Zip Code:96789-5342
Mailing Address - Country:US
Mailing Address - Phone:860-819-8570
Mailing Address - Fax:
Practice Address - Street 1:1 JARRETT WHITE RD
Practice Address - Street 2:
Practice Address - City:TRIPLER AMC
Practice Address - State:HI
Practice Address - Zip Code:96859-5001
Practice Address - Country:US
Practice Address - Phone:860-819-8570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000729101YA0400X
CT0061941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004262945Medicaid
CT004262945Medicaid