Provider Demographics
NPI:1235734765
Name:BENNETT, BRENDA S
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:S
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 1:2011 S 25TH ST STE 108
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34947-4795
Mailing Address - Country:US
Mailing Address - Phone:772-242-1079
Mailing Address - Fax:772-242-1296
Practice Address - Street 1:2011 S 25TH ST STE 108
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34947-4795
Practice Address - Country:US
Practice Address - Phone:772-242-1079
Practice Address - Fax:772-242-1296
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
103T00000XOther103T00000X