Provider Demographics
NPI:1972255008
Name:BENNETT, AUDREY (LMFT)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:
Other - Last Name:GLAIZE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MFTA
Mailing Address - Street 1:409 MARQUETTE DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-4719
Mailing Address - Country:US
Mailing Address - Phone:502-785-5200
Mailing Address - Fax:
Practice Address - Street 1:409 MARQUETTE DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-4719
Practice Address - Country:US
Practice Address - Phone:502-785-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-20
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY271888106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist