Provider Demographics
NPI:1447743414
Name:BENNETT, LEATHA
Entity Type:Individual
Prefix:
First Name:LEATHA
Middle Name:
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 1:408 NORFOLK ST
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER CENTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-4009
Mailing Address - Country:US
Mailing Address - Phone:781-562-9340
Mailing Address - Fax:
Practice Address - Street 1:400 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-4729
Practice Address - Country:US
Practice Address - Phone:781-817-6386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-13
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health