Healthcare Provider Details

I. General information

NPI: 1164108429
Provider Name (Legal Business Name): VIKTORIJA BENNETT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2023
Last Update Date: 10/17/2023
Certification Date: 10/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10204 BODE ST STE B
PLAINFIELD IL
60585-9813
US

IV. Provider business mailing address

PO BOX 679
CAMDEN NY
13316-0679
US

V. Phone/Fax

Practice location:
  • Phone: 630-896-7160
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.1200556-SUPV
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: