Healthcare Provider Details

I. General information

NPI: 1114904067
Provider Name (Legal Business Name): PAULETTE BENNETT LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2005
Last Update Date: 09/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121A BELLEVUE RD
DUBLIN GA
31021-2998
US

IV. Provider business mailing address

392 RODDY HWY
EASTMAN GA
31023-2718
US

V. Phone/Fax

Practice location:
  • Phone: 478-272-1190
  • Fax: 478-275-6509
Mailing address:
  • Phone: 478-374-7432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number001998
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: