Healthcare Provider Details

I. General information

NPI: 1124820444
Provider Name (Legal Business Name): STEPHEN BENNETT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2025
Last Update Date: 03/26/2025
Certification Date: 03/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 BRENTWOOD DR
GRASS VALLEY CA
95945-5703
US

IV. Provider business mailing address

159 BRENTWOOD DR
GRASS VALLEY CA
95945-5703
US

V. Phone/Fax

Practice location:
  • Phone: 530-273-9541
  • Fax:
Mailing address:
  • Phone: 530-273-9541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number21054
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: