Healthcare Provider Details

I. General information

NPI: 1104141175
Provider Name (Legal Business Name): HEIDI SUE BENNETT LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2010
Last Update Date: 10/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

89 MAIN ST
MEXICO ME
04257-1440
US

IV. Provider business mailing address

235 MAIN ST
NORWAY ME
04268-5943
US

V. Phone/Fax

Practice location:
  • Phone: 207-739-2644
  • Fax: 207-739-2467
Mailing address:
  • Phone: 207-739-2644
  • Fax: 207-739-2467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCAC3731
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLC5006
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: