Provider Demographics
NPI:1558507012
Name:BENNETT, BRADFORD S (LCSW)
Entity Type:Individual
Prefix:
First Name:BRADFORD
Middle Name:S
Last Name:BENNETT
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N MERIDIAN ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4459
Mailing Address - Country:US
Mailing Address - Phone:317-962-4942
Mailing Address - Fax:
Practice Address - Street 1:1701 N SENATE BLVD
Practice Address - Street 2:RM AG022
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1239
Practice Address - Country:US
Practice Address - Phone:317-962-2622
Practice Address - Fax:317-963-5424
Is Sole Proprietor?:No
Enumeration Date:2009-01-05
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN340052921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN264430FFFMedicare PIN
INP00816012Medicare PIN
IN676310LMedicare PIN