Provider Demographics
NPI:1790417798
Name:BENNETT, ANGELA
Entity Type:Individual
Prefix:
First Name:ANGELA
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 1:4514 SAGE LN
Mailing Address - Street 2:
Mailing Address - City:MELISSA
Mailing Address - State:TX
Mailing Address - Zip Code:75454-0754
Mailing Address - Country:US
Mailing Address - Phone:702-904-0869
Mailing Address - Fax:
Practice Address - Street 1:4514 SAGE LN
Practice Address - Street 2:
Practice Address - City:MELISSA
Practice Address - State:TX
Practice Address - Zip Code:75454-0754
Practice Address - Country:US
Practice Address - Phone:702-904-0869
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-28
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1069161041C0700X
NV9956-M1041C0700X
AZLMSW-203881041C0700X
TX1074461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical