MEDICARE: TONYA BENNETT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310500000X	Mental Illness Intermediate Care Facility
2	171M00000X	Case Manager/Care Coordinator

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	123456	OTHER		RECOVERY WORKS

General Provider Information

NPI Number	:	1144794454
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TONYA BENNETT

Provider Business Mailing Address
First Line	:	2702 ETHEL AVE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46208-5160
Country	:	US
Telephone Number	:	317-772-2673
Fax Number	:

Provider Business Practice Location Address
First Line	:	2702 ETHEL AVE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46208-5160
Country	:	US
Telephone Number	:	317-772-2673
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/20/2019
Last Update Date	:	01/24/2019

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Directions to “ TONYA BENNETT ” Practice Location

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