Provider Demographics
NPI:1790089589
Name:BENNETT, NICOLE AMELIA
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:AMELIA
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 1:1830 DAIRY AVE APT 314
Mailing Address - Street 2:
Mailing Address - City:CORCORAN
Mailing Address - State:CA
Mailing Address - Zip Code:93212-2985
Mailing Address - Country:US
Mailing Address - Phone:559-381-6434
Mailing Address - Fax:
Practice Address - Street 1:7170 N FINANCIAL DR STE 135
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-2978
Practice Address - Country:US
Practice Address - Phone:559-221-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-07
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)