Provider Demographics
NPI:1316220932
Name:BENNETT, SETH ALAN
Entity Type:Individual
Prefix:
First Name:SETH
Middle Name:ALAN
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 1:301A WASHINGTON
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:AR
Mailing Address - Zip Code:71701
Mailing Address - Country:US
Mailing Address - Phone:870-836-2321
Mailing Address - Fax:870-837-1195
Practice Address - Street 1:301A WASHINGTON
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:AR
Practice Address - Zip Code:71701
Practice Address - Country:US
Practice Address - Phone:870-836-2321
Practice Address - Fax:870-837-1195
Is Sole Proprietor?:No
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR174662526Medicaid