Provider Demographics
NPI:1295882736
Name:BENNETT, MARILYN (LMHC)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2593 S PARK AVE
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-5147
Mailing Address - Country:US
Mailing Address - Phone:321-631-5538
Mailing Address - Fax:321-631-5154
Practice Address - Street 1:1 OLEANDER ST STE 3
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32922-7900
Practice Address - Country:US
Practice Address - Phone:321-631-5538
Practice Address - Fax:321-631-5154
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101YM0800X
FLMH 7681101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0764698 00Medicaid