Provider Demographics
NPI:1326512120
Name:BENNETT, CRYSTAL RAE
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:RAE
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 1:2107 SPRUCE STREET
Mailing Address - Street 2:
Mailing Address - City:NORTH COLLINS
Mailing Address - State:NY
Mailing Address - Zip Code:14111
Mailing Address - Country:US
Mailing Address - Phone:716-337-3706
Mailing Address - Fax:716-337-2723
Practice Address - Street 1:2107 SPRUCE STREET
Practice Address - Street 2:
Practice Address - City:NORTH COLLINS
Practice Address - State:NY
Practice Address - Zip Code:14111
Practice Address - Country:US
Practice Address - Phone:716-337-3706
Practice Address - Fax:716-337-2723
Is Sole Proprietor?:No
Enumeration Date:2019-01-15
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor