Healthcare Provider Details

I. General information

NPI: 1295099737
Provider Name (Legal Business Name): SHERMIKA RIA BENNETT MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2012
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1313 MILSTEAD AVE NE
CONYERS GA
30012-3829
US

IV. Provider business mailing address

2705 LAUREL CHERRY LN SE
CONYERS GA
30094-4519
US

V. Phone/Fax

Practice location:
  • Phone: 404-495-7447
  • Fax: 470-682-3642
Mailing address:
  • Phone: 470-265-0109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: