Healthcare Provider Details

I. General information

NPI: 1508057548
Provider Name (Legal Business Name): LAURA LEE BENNETT MA., LLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2007
Last Update Date: 08/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 PARCHMENT DR SE
GRAND RAPIDS MI
49546-3664
US

IV. Provider business mailing address

1007 PARCHMENT DR SE
GRAND RAPIDS MI
49546-3664
US

V. Phone/Fax

Practice location:
  • Phone: 616-690-0434
  • Fax:
Mailing address:
  • Phone: 616-690-0434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number6301011875
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: