Provider Demographics
NPI:1932618444
Name:BENNETT, DAVID LOUIS
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:LOUIS
Last Name:BENNETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3007 KNIGHT ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-2525
Mailing Address - Country:US
Mailing Address - Phone:318-221-8244
Mailing Address - Fax:318-861-2162
Practice Address - Street 1:3007 KNIGHT ST.
Practice Address - Street 2:SUITE 200
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105
Practice Address - Country:US
Practice Address - Phone:318-221-8244
Practice Address - Fax:318-861-2162
Is Sole Proprietor?:No
Enumeration Date:2017-09-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
LA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA72-0694376Medicaid