Provider Demographics
NPI:1356078208
Name:BENNETT, SHANA (LCSW)
Entity type:Individual
Prefix:
First Name:SHANA
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6441 S CHICKASAW TRL # 193
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32829-8366
Mailing Address - Country:US
Mailing Address - Phone:551-900-1519
Mailing Address - Fax:
Practice Address - Street 1:9405 DOWDEN RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32832-5612
Practice Address - Country:US
Practice Address - Phone:551-900-1519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-02
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL199341041C0700X
NY0919691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical