Provider Demographics
NPI:1720059819
Name:BENNETT, MARLO KATHLEEN (LMFT)
Entity Type:Individual
Prefix:MS
First Name:MARLO
Middle Name:KATHLEEN
Last Name:BENNETT
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:MS
Other - First Name:MARLO
Other - Middle Name:
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMFT
Mailing Address - Street 1:1901 PROSPECTOR AVENUE
Mailing Address - Street 2:STE 22
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84060
Mailing Address - Country:US
Mailing Address - Phone:435-901-3218
Mailing Address - Fax:
Practice Address - Street 1:1901 PROSPECTOR AVE STE 22
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84060-7208
Practice Address - Country:US
Practice Address - Phone:435-901-3218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT357426-3902101YA0400X, 106H00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist