Provider Demographics
NPI:1326680760
Name:BENNETT-MELENDEZ, SUSANA DORIAN
Entity Type:Individual
Prefix:
First Name:SUSANA
Middle Name:DORIAN
Last Name:BENNETT-MELENDEZ
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:PO BOX 149
Mailing Address - Street 2:
Mailing Address - City:OUZINKIE
Mailing Address - State:AK
Mailing Address - Zip Code:99644-0149
Mailing Address - Country:US
Mailing Address - Phone:907-486-1390
Mailing Address - Fax:
Practice Address - Street 1:3449 E REZANOF DR
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615-6952
Practice Address - Country:US
Practice Address - Phone:907-486-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-16
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK19-161-BHA1101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor