Provider Demographics
NPI:1619639168
Name:BENNETT, KEYONA HARDISON
Entity Type:Individual
Prefix:
First Name:KEYONA
Middle Name:HARDISON
Last Name:BENNETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1129 WINDBLOW RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:27281-9114
Mailing Address - Country:US
Mailing Address - Phone:910-995-6211
Mailing Address - Fax:
Practice Address - Street 1:1129 WINDBLOW RD
Practice Address - Street 2:
Practice Address - City:JACKSON SPRINGS
Practice Address - State:NC
Practice Address - Zip Code:27281-9114
Practice Address - Country:US
Practice Address - Phone:910-995-6211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0167801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical