Provider Demographics
NPI:1134483787
Name:BENNETT-MEDICIS, EMILIE (MA)
Entity Type:Individual
Prefix:
First Name:EMILIE
Middle Name:
Last Name:BENNETT-MEDICIS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44447 10TH ST W
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-3324
Mailing Address - Country:US
Mailing Address - Phone:661-726-2630
Mailing Address - Fax:661-723-3211
Practice Address - Street 1:44447 10TH ST W
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-3324
Practice Address - Country:US
Practice Address - Phone:661-726-2630
Practice Address - Fax:661-723-3211
Is Sole Proprietor?:No
Enumeration Date:2012-06-28
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA74624106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist