Provider Demographics
NPI:1942714951
Name:BENNIE, JOHN ROBERT (MA LBSW QMHP)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ROBERT
Last Name:BENNIE
Suffix:
Gender:M
Credentials:MA LBSW QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405B S 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:BIG RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49307-8884
Mailing Address - Country:US
Mailing Address - Phone:231-592-4654
Mailing Address - Fax:231-592-4657
Practice Address - Street 1:405B S 3RD AVE
Practice Address - Street 2:
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307-8884
Practice Address - Country:US
Practice Address - Phone:231-592-4654
Practice Address - Fax:231-592-4657
Is Sole Proprietor?:No
Enumeration Date:2017-11-29
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68020579491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6802057949Medicaid