Provider Demographics
NPI:1558825893
Name:BENNETT, ERIC J (CMS)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:J
Last Name:BENNETT
Suffix:
Gender:M
Credentials:CMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:178 GINAT DR
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN FURNACE
Mailing Address - State:OH
Mailing Address - Zip Code:45629-8822
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14574 US HIGHWAY 23
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:OH
Practice Address - Zip Code:45690-9373
Practice Address - Country:US
Practice Address - Phone:740-464-4473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-30
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
OH314669163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)