Provider Demographics
NPI:1689189995
Name:BENNETT, NOELLE
Entity Type:Individual
Prefix:
First Name:NOELLE
Middle Name:
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 1:175 E HAWTHORN PKWY STE 235
Mailing Address - Street 2:
Mailing Address - City:VERNON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60061-1454
Mailing Address - Country:US
Mailing Address - Phone:847-737-8768
Mailing Address - Fax:847-859-5885
Practice Address - Street 1:4615 E STATE ST STE 202
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2158
Practice Address - Country:US
Practice Address - Phone:847-868-3435
Practice Address - Fax:847-859-5885
Is Sole Proprietor?:No
Enumeration Date:2017-12-08
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
178014161101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator