Provider Demographics
NPI:1134199854
Name:BENNETT, GRETCHEN A (MA CCC SLP)
Entity type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:A
Last Name:BENNETT
Suffix:
Gender:F
Credentials:MA CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 BIOMEDICAL EDUCATION BLDG
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14214-8016
Mailing Address - Country:US
Mailing Address - Phone:716-829-3980
Mailing Address - Fax:716-829-3974
Practice Address - Street 1:52 BIOMEDICAL EDUCATION BLDG
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14214-8016
Practice Address - Country:US
Practice Address - Phone:716-829-3980
Practice Address - Fax:716-829-3974
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0119351235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
00011240404OtherUNIVERA
020571380OtherNORTH AMERICAN PREFERRED
GRP512343002OtherBCBS GROUP
9210117OtherINDEPENDENT HEALTH
000640207001OtherBCCB
020571380OtherTAX ID