Provider Demographics
NPI:1437443504
Name:BENNETT, MYRA F (CAP-128)
Entity Type:Individual
Prefix:
First Name:MYRA
Middle Name:F
Last Name:BENNETT
Suffix:
Gender:F
Credentials:CAP-128
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1106 JULIE LN
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:WY
Mailing Address - Zip Code:82435-1632
Mailing Address - Country:US
Mailing Address - Phone:307-754-7460
Mailing Address - Fax:307-271-7460
Practice Address - Street 1:1106 JULIE LN
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:WY
Practice Address - Zip Code:82435-1632
Practice Address - Country:US
Practice Address - Phone:307-271-7460
Practice Address - Fax:307-271-7460
Is Sole Proprietor?:No
Enumeration Date:2011-06-06
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYCAP-128101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)