Provider Demographics
NPI:1790901171
Name:BENNETT, MYRA LYN (LCPT)
Entity Type:Individual
Prefix:
First Name:MYRA
Middle Name:LYN
Last Name:BENNETT
Suffix:
Gender:F
Credentials:LCPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5350 POPLAR AVE STE 730
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-3697
Mailing Address - Country:US
Mailing Address - Phone:901-683-5658
Mailing Address - Fax:901-684-1277
Practice Address - Street 1:5350 POPLAR AVE STE 730
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-3697
Practice Address - Country:US
Practice Address - Phone:901-683-5658
Practice Address - Fax:901-684-1277
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0022101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral