MEDICARE: KENNETHRA WALLACE 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	106E00000X	Assistant Behavior Analyst

General Provider Information

NPI Number	:	1508711425
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETHRA WALLACE BENNETT

Provider Business Mailing Address
First Line	:	7108 SOUTH KANNER HWY
Second Line	:
City	:	STUART
State	:	FL
Zip	:	34997-7462
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1101 W 34TH STREET
Second Line	:	#443
City	:	AUSTIN
State	:	TX
Zip	:	78705-1907
Country	:	US
Telephone Number	:	855-832-6727
Fax Number	:

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

Provider Enumeration Date	:	03/04/2026
Last Update Date	:	03/04/2026

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