Provider Demographics
NPI:1194034454
Name:BENNETT, GREGORY JAMES (LAT)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:JAMES
Last Name:BENNETT
Suffix:
Gender:M
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1051 MORNING GLORY LN
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:WY
Mailing Address - Zip Code:82435-2266
Mailing Address - Country:US
Mailing Address - Phone:307-254-2038
Mailing Address - Fax:
Practice Address - Street 1:249 E 2ND ST STE 1
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:WY
Practice Address - Zip Code:82435-1959
Practice Address - Country:US
Practice Address - Phone:307-254-2038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-04
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLAT326101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)