Provider Demographics
NPI:1669509832
Name:COOLEY BENNETT, TERESA ANNE (LCSW, LSCSW, CCDP-D)
Entity Type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:ANNE
Last Name:COOLEY BENNETT
Suffix:
Gender:F
Credentials:LCSW, LSCSW, CCDP-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 NW CORTLAND DR
Mailing Address - Street 2:
Mailing Address - City:BLUE SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64015-3669
Mailing Address - Country:US
Mailing Address - Phone:816-516-6514
Mailing Address - Fax:
Practice Address - Street 1:3801 DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64130-2807
Practice Address - Country:US
Practice Address - Phone:816-599-5638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLSCSW 38521041C0700X
MO5526174400000X
MO20001644071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO495372203Medicaid
000C334OtherMEDICARE PROVIDER ID #
KS200579670AMedicaid
KS200579670AMedicaid