Provider Demographics
NPI:1558140517
Name:BENNETT, POONAM BAILEY
Entity Type:Individual
Prefix:MS
First Name:POONAM
Middle Name:BAILEY
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 1:1800 S 35TH ST
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:MI
Mailing Address - Zip Code:49053-9688
Mailing Address - Country:US
Mailing Address - Phone:269-250-8200
Mailing Address - Fax:
Practice Address - Street 1:1800 S 35TH ST
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:MI
Practice Address - Zip Code:49053-9688
Practice Address - Country:US
Practice Address - Phone:269-250-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-27
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician