Healthcare Provider Details

I. General information

NPI: 1275233132
Provider Name (Legal Business Name): CASEY MILES BENNETT LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2023
Last Update Date: 07/31/2023
Certification Date: 07/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9414 BELAIR RD STE 201
NOTTINGHAM MD
21236-1542
US

IV. Provider business mailing address

9414 BELAIR RD STE 201
NOTTINGHAM MD
21236-1542
US

V. Phone/Fax

Practice location:
  • Phone: 410-529-2151
  • Fax:
Mailing address:
  • Phone: 410-529-2151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC14101
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: