Provider Demographics
NPI:1710250592
Name:BENNETT, MARIETTA (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARIETTA
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5011 BELL BLVD
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11364-1202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5011 BELL BLVD
Practice Address - Street 2:
Practice Address - City:BAYSIDE HILLS
Practice Address - State:NY
Practice Address - Zip Code:11364-1202
Practice Address - Country:US
Practice Address - Phone:845-641-8366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-09
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018560-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist