Provider Demographics
NPI:1114796059
Name:BENNETT, ELIJAH MICHAEL
Entity Type:Individual
Prefix:
First Name:ELIJAH
Middle Name:MICHAEL
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 1:4623 W MAGDALENA LN
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-2355
Mailing Address - Country:US
Mailing Address - Phone:425-273-3789
Mailing Address - Fax:
Practice Address - Street 1:4623 W MAGDALENA LN
Practice Address - Street 2:
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339-2355
Practice Address - Country:US
Practice Address - Phone:425-273-3789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-20
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician