Provider Demographics
NPI:1821044900
Name:BENNETT, MARY ELLEN (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16935 W BERNARDO DR
Mailing Address - Street 2:SUITE 208
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-1634
Mailing Address - Country:US
Mailing Address - Phone:858-218-6653
Mailing Address - Fax:858-451-0333
Practice Address - Street 1:16935 W BERNARDO DR
Practice Address - Street 2:SUITE 208
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92127-1634
Practice Address - Country:US
Practice Address - Phone:858-218-6653
Practice Address - Fax:858-451-0333
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS204061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASW20406Medicare PIN
CAW416Medicare PIN