Provider Demographics
NPI:1174025712
Name:BENNETT, RYAN S (QMHS, CDCA, PRS)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:S
Last Name:BENNETT
Suffix:
Gender:M
Credentials:QMHS, CDCA, PRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6629 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43617
Mailing Address - Country:US
Mailing Address - Phone:419-354-4200
Mailing Address - Fax:
Practice Address - Street 1:309 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-3010
Practice Address - Country:US
Practice Address - Phone:419-722-0431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-28
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH150233101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health