Provider Demographics
NPI:1144794454
Name:BENNETT, TONYA
Entity Type:Individual
Prefix:
First Name:TONYA
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 1:2702 ETHEL AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46208-5160
Mailing Address - Country:US
Mailing Address - Phone:317-772-2673
Mailing Address - Fax:
Practice Address - Street 1:2702 ETHEL AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46208-5160
Practice Address - Country:US
Practice Address - Phone:317-772-2673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-20
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
123456OtherRECOVERY WORKS