Provider Demographics
NPI:1780710442
Name:MAIN-BENNETT, PENNY (LADC)
Entity type:Individual
Prefix:MS
First Name:PENNY
Middle Name:
Last Name:MAIN-BENNETT
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4003 SUNSHINE DR
Mailing Address - Street 2:
Mailing Address - City:ANOKA
Mailing Address - State:MN
Mailing Address - Zip Code:55303-8606
Mailing Address - Country:US
Mailing Address - Phone:763-413-8838
Mailing Address - Fax:763-413-8878
Practice Address - Street 1:16525 HIGHWAY 65 NE
Practice Address - Street 2:
Practice Address - City:HAM LAKE X
Practice Address - State:MN
Practice Address - Zip Code:55304-5300
Practice Address - Country:US
Practice Address - Phone:763-413-8838
Practice Address - Fax:763-413-8878
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN300832101YA0400X
MN1010135-1-CDT101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN5040353OtherUBH
MN6C74GROtherBCBS OF MN
MN1030158OtherPREFERRED ONE