Provider Demographics
NPI:1093832362
Name:BENNETT-TELOH, PAMLA (LCSW)
Entity Type:Individual
Prefix:
First Name:PAMLA
Middle Name:
Last Name:BENNETT-TELOH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 W MAIN ST
Mailing Address - Street 2:STE. 204
Mailing Address - City:INVERNESS
Mailing Address - State:FL
Mailing Address - Zip Code:34450-4811
Mailing Address - Country:US
Mailing Address - Phone:352-637-5939
Mailing Address - Fax:
Practice Address - Street 1:111 W MAIN ST
Practice Address - Street 2:STE. 204
Practice Address - City:INVERNESS
Practice Address - State:FL
Practice Address - Zip Code:34450-4811
Practice Address - Country:US
Practice Address - Phone:352-637-5939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 101YM0800X
FLSW7567101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSW7567OtherLICENSE NUMBER
FLU4927Medicare ID - Type Unspecified