Provider Demographics
NPI:1982100632
Name:BENNETT, SIARRA T
Entity Type:Individual
Prefix:
First Name:SIARRA
Middle Name:T
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 1:1021 W COLUMBIA AVE APT B
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-2032
Mailing Address - Country:US
Mailing Address - Phone:520-221-8410
Mailing Address - Fax:
Practice Address - Street 1:618 S ALDER ST
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-1760
Practice Address - Country:US
Practice Address - Phone:509-764-6644
Practice Address - Fax:509-764-6676
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-02
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician