Provider Demographics
NPI:1609407774
Name:BENNETT, SIERRA (CO 61034482)
Entity Type:Individual
Prefix:
First Name:SIERRA
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:CO 61034482
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:WA
Mailing Address - Zip Code:98520-4106
Mailing Address - Country:US
Mailing Address - Phone:360-350-4010
Mailing Address - Fax:360-533-9825
Practice Address - Street 1:516 E 1ST ST
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520-4106
Practice Address - Country:US
Practice Address - Phone:360-350-4010
Practice Address - Fax:360-533-9825
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61034482101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA33-0652655Medicaid