Provider Demographics
NPI:1114536018
Name:BENNETT, SAMUEL RICHARD
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:RICHARD
Last Name:BENNETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1465 LAKE DR
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-2405
Mailing Address - Country:US
Mailing Address - Phone:815-207-3975
Mailing Address - Fax:
Practice Address - Street 1:5214 N WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-2589
Practice Address - Country:US
Practice Address - Phone:773-250-1769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-27
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health