Provider Demographics
NPI:1407191877
Name:BENNETT, ESHELLE (RRW)
Entity Type:Individual
Prefix:
First Name:ESHELLE
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:RRW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16248 VICTOR ST
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-3934
Mailing Address - Country:US
Mailing Address - Phone:760-243-7151
Mailing Address - Fax:760-952-1432
Practice Address - Street 1:16248 VICTOR ST
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-3934
Practice Address - Country:US
Practice Address - Phone:760-243-7151
Practice Address - Fax:760-952-1432
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-11
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARW6488101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)