Provider Demographics
NPI:1205964715
Name:BENNETT, MATILDE (MED, LPC)
Entity type:Individual
Prefix:MS
First Name:MATILDE
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:MRS
Other - First Name:MATILDE
Other - Middle Name:B
Other - Last Name:MENDOZA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:355 W ELIZABETH ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78520-5793
Mailing Address - Country:US
Mailing Address - Phone:956-544-7744
Mailing Address - Fax:
Practice Address - Street 1:355 W ELIZABETH ST
Practice Address - Street 2:SUITE 203
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78520-5793
Practice Address - Country:US
Practice Address - Phone:956-544-7744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX59157101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX182765101Medicaid