Provider Demographics
NPI:1477232601
Name:KERRY BENNETT, LLC
Entity Type:Organization
Organization Name:KERRY BENNETT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:206-930-6435
Mailing Address - Street 1:117 SUMMIT TER APT 96
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2276
Mailing Address - Country:US
Mailing Address - Phone:206-930-6435
Mailing Address - Fax:
Practice Address - Street 1:541 OCEAN HOUSE RD
Practice Address - Street 2:
Practice Address - City:CAPE ELIZABETH
Practice Address - State:ME
Practice Address - Zip Code:04107-2607
Practice Address - Country:US
Practice Address - Phone:206-930-6435
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-14
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)