MEDICARE: KEYONA HARDISON 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	1041C0700X	Clinical Social Worker	P016780	NC

General Provider Information

NPI Number	:	1619639168
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEYONA HARDISON BENNETT

Provider Business Mailing Address
First Line	:	1129 WINDBLOW RD
Second Line	:
City	:	JACKSON SPRINGS
State	:	NC
Zip	:	27281-9114
Country	:	US
Telephone Number	:	910-995-6211
Fax Number	:

Provider Business Practice Location Address
First Line	:	1129 WINDBLOW RD
Second Line	:
City	:	JACKSON SPRINGS
State	:	NC
Zip	:	27281-9114
Country	:	US
Telephone Number	:	910-995-6211
Fax Number	:

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

Provider Enumeration Date	:	10/12/2021
Last Update Date	:	10/12/2021

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