Provider Demographics
NPI:1184667172
Name:BENNETT, EDWIN TALCOTT (MSW-LCSW)
Entity Type:Individual
Prefix:MR
First Name:EDWIN
Middle Name:TALCOTT
Last Name:BENNETT
Suffix:
Gender:M
Credentials:MSW-LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2028 N SEMINARY AVE
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-2626
Mailing Address - Country:US
Mailing Address - Phone:815-333-8651
Mailing Address - Fax:
Practice Address - Street 1:2028 N SEMINARY AVE
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-2626
Practice Address - Country:US
Practice Address - Phone:815-333-8651
Practice Address - Fax:815-337-4406
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK28321Medicare ID - Type Unspecified