Healthcare Provider Details

I. General information

NPI: 1447884481
Provider Name (Legal Business Name): SARA J BENNETT LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2020
Last Update Date: 01/14/2021
Certification Date: 01/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SAINT ANTHONYS WAY
ALTON IL
62002-4568
US

IV. Provider business mailing address

902 W MAIN ST
WEST FRANKFORT IL
62896-2210
US

V. Phone/Fax

Practice location:
  • Phone: 618-474-6240
  • Fax: 618-474-6242
Mailing address:
  • Phone: 618-937-6483
  • Fax: 618-937-1440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149022687
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: