MEDICARE: MINETTE BENNETT MA, LPC

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	101YP2500X	Professional Counselor	C5716	OR

General Provider Information

NPI Number	:	1407221617
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MINETTE BENNETT MA, LPC

Provider Business Mailing Address
First Line	:	4898 FOX LN S
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97306-9726
Country	:	US
Telephone Number	:	503-509-7413
Fax Number	:	503-694-7794

Provider Business Practice Location Address
First Line	:	3295 TRIANGLE DR SE STE 100
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97302-4566
Country	:	US
Telephone Number	:	503-509-7413
Fax Number	:	503-694-7794

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

Provider Enumeration Date	:	12/14/2015
Last Update Date	:	05/03/2022

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Directions to “ MINETTE BENNETT MA, LPC” Practice Location

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