Provider Demographics
NPI:1134644966
Name:BENNETT, MIA
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3308 TULANE AVE STE 407
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-7158
Mailing Address - Country:US
Mailing Address - Phone:504-821-6830
Mailing Address - Fax:504-821-6837
Practice Address - Street 1:3308 TULANE AVE STE 407
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-7158
Practice Address - Country:US
Practice Address - Phone:504-821-6830
Practice Address - Fax:504-821-6837
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2138880Medicaid