Provider Demographics
NPI:1942703806
Name:BENNETT, KATINA LYNN (LLPC)
Entity Type:Individual
Prefix:
First Name:KATINA
Middle Name:LYNN
Last Name:BENNETT
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54710 BATES RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48051-1621
Mailing Address - Country:US
Mailing Address - Phone:586-219-2791
Mailing Address - Fax:
Practice Address - Street 1:54710 BATES RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MI
Practice Address - Zip Code:48051-1621
Practice Address - Country:US
Practice Address - Phone:586-219-2791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-16
Last Update Date:2018-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401016114101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor