MEDICARE: MS. MARLO KATHLEEN BENNETT LMFT

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	357426-3902	UT
2	106H00000X	Marriage & Family Therapist	357426-3902	UT
3	101YM0800X	Mental Health Counselor	357426-3902	UT

General Provider Information

NPI Number	:	1720059819
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARLO KATHLEEN BENNETT LMFT

Provider Business Mailing Address
First Line	:	1901 PROSPECTOR AVENUE
Second Line	:	STE 22
City	:	PARK CITY
State	:	UT
Zip	:	84060
Country	:	US
Telephone Number	:	435-901-3218
Fax Number	:

Provider Business Practice Location Address
First Line	:	1901 PROSPECTOR AVE STE 22
Second Line	:
City	:	PARK CITY
State	:	UT
Zip	:	84060-7208
Country	:	US
Telephone Number	:	435-901-3218
Fax Number	:

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

Provider Enumeration Date	:	01/27/2006
Last Update Date	:	08/29/2019

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