Provider Demographics
NPI:1629223730
Name:BENNETT, PHILLIP WHAYNE (LCSW)
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:WHAYNE
Last Name:BENNETT
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 PIKE STREET
Mailing Address - Street 2:
Mailing Address - City:PORT JERVIS
Mailing Address - State:NY
Mailing Address - Zip Code:12771
Mailing Address - Country:US
Mailing Address - Phone:845-858-1456
Mailing Address - Fax:845-858-1459
Practice Address - Street 1:146 PIKE STREET
Practice Address - Street 2:
Practice Address - City:PORT JERVIS
Practice Address - State:NY
Practice Address - Zip Code:12771
Practice Address - Country:US
Practice Address - Phone:845-858-1456
Practice Address - Fax:845-858-1459
Is Sole Proprietor?:No
Enumeration Date:2008-11-18
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY075663-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03004253Medicaid
NY03004253Medicaid