Provider Demographics
NPI:1255004909
Name:BENNETT, ADAM TAYLOR
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:TAYLOR
Last Name:BENNETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2519 RYAN ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-7323
Mailing Address - Country:US
Mailing Address - Phone:337-491-0800
Mailing Address - Fax:337-491-0508
Practice Address - Street 1:2519 RYAN ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-7323
Practice Address - Country:US
Practice Address - Phone:337-491-0800
Practice Address - Fax:337-491-0508
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-28
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL-559103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst