Provider Demographics
NPI:1497117105
Name:BENNETT, GRACE (LICSW)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:927 TRETTEL LN
Mailing Address - Street 2:
Mailing Address - City:CLOQUET
Mailing Address - State:MN
Mailing Address - Zip Code:55720-1345
Mailing Address - Country:US
Mailing Address - Phone:218-879-1227
Mailing Address - Fax:
Practice Address - Street 1:927 TRETTEL LN
Practice Address - Street 2:
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720-1345
Practice Address - Country:US
Practice Address - Phone:218-879-1227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN158991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical