Provider Demographics
NPI:1558623231
Name:BENNETT, SANDY S (LCSW)
Entity Type:Individual
Prefix:
First Name:SANDY
Middle Name:S
Last Name:BENNETT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 BEACHWAY DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46224-8506
Mailing Address - Country:US
Mailing Address - Phone:317-788-4111
Mailing Address - Fax:317-788-7783
Practice Address - Street 1:23 S 8TH ST
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-2605
Practice Address - Country:US
Practice Address - Phone:317-788-4111
Practice Address - Fax:317-788-7763
Is Sole Proprietor?:No
Enumeration Date:2012-06-08
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34003415A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN34003415AOtherLICENSED CLINICAL SOCIAL WORKER