Provider Demographics
NPI:1679116552
Name:BENNETT, RACHEL LOGAN
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:LOGAN
Last Name:BENNETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RACHEL
Other - Middle Name:FALK
Other - Last Name:LOGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3630 N BOSWORTH AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-5741
Mailing Address - Country:US
Mailing Address - Phone:781-572-8113
Mailing Address - Fax:
Practice Address - Street 1:6639 N KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60645-4161
Practice Address - Country:US
Practice Address - Phone:773-765-3122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-23
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801105825104100000X
IL149.0240561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker