Provider Demographics
NPI:1588808059
Name:BENNETTS, KRYSTAL MARIE (MA, LLP)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:MARIE
Last Name:BENNETTS
Suffix:
Gender:F
Credentials:MA, LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18316 MIDDLEBELT RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-5007
Mailing Address - Country:US
Mailing Address - Phone:248-615-9730
Mailing Address - Fax:
Practice Address - Street 1:18316 MIDDLEBELT RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-5007
Practice Address - Country:US
Practice Address - Phone:248-615-9730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-28
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013383103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical