Provider Demographics
NPI:1871868406
Name:BENNETT, MISHA (LCSW)
Entity Type:Individual
Prefix:
First Name:MISHA
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 1:9615 E 148TH ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46060-4360
Mailing Address - Country:US
Mailing Address - Phone:317-587-0533
Mailing Address - Fax:317-674-0059
Practice Address - Street 1:602 RANSDELL RD
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:IN
Practice Address - Zip Code:46052-2349
Practice Address - Country:US
Practice Address - Phone:765-482-7100
Practice Address - Fax:317-674-0059
Is Sole Proprietor?:No
Enumeration Date:2012-03-15
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34006526A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical