Provider Demographics
NPI:1467788364
Name:BENNETT, MICHAEL MARTIN (LAC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:MARTIN
Last Name:BENNETT
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75-377 HUALALAI RD
Mailing Address - Street 2:
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96740-9724
Mailing Address - Country:US
Mailing Address - Phone:808-329-0774
Mailing Address - Fax:808-329-0076
Practice Address - Street 1:75-377 HUALALAI RD
Practice Address - Street 2:
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-9724
Practice Address - Country:US
Practice Address - Phone:808-329-0774
Practice Address - Fax:808-329-0076
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-27
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT667101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT667OtherLAC