Provider Demographics
NPI:1881455194
Name:BENNETT, SKYE LORREN
Entity type:Individual
Prefix:
First Name:SKYE
Middle Name:LORREN
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 1:2221 M ST NE APT 101
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-2058
Mailing Address - Country:US
Mailing Address - Phone:410-302-3994
Mailing Address - Fax:
Practice Address - Street 1:10513 JUDICIAL DR STE 201
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-7528
Practice Address - Country:US
Practice Address - Phone:703-672-1474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-23
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704016477101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health