Provider Demographics
NPI:1457720138
Name:BENNETT, RATONYA
Entity Type:Individual
Prefix:
First Name:RATONYA
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6251 BUNCOMBE RD
Mailing Address - Street 2:5
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71129-4340
Mailing Address - Country:US
Mailing Address - Phone:318-426-1298
Mailing Address - Fax:
Practice Address - Street 1:6251 BUNCOMBE RD
Practice Address - Street 2:5
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71129-4340
Practice Address - Country:US
Practice Address - Phone:318-426-1298
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-23
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3101101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional