Provider Demographics
NPI:1912214750
Name:CARRILLO BENNETT, DANELLE MARIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:DANELLE
Middle Name:MARIE
Last Name:CARRILLO BENNETT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18201 CONNEAUT LAKE RD
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-3757
Mailing Address - Country:US
Mailing Address - Phone:814-333-5061
Mailing Address - Fax:814-333-5067
Practice Address - Street 1:18201 CONNEAUT LAKE RD
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-3757
Practice Address - Country:US
Practice Address - Phone:814-333-5061
Practice Address - Fax:814-333-5067
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-31
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC005567101YP2500X
PAPS017424103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional