Healthcare Provider Details

I. General information

NPI: 1720941230
Provider Name (Legal Business Name): TANEKA M BENNETT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2025
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1183 UNIVERSITY DRIVE, SUITE 105 PMB 1018
BURLINGTON NC
27215-8315
US

IV. Provider business mailing address

1183 UNIVERSITY DRIVE, SUITE 105 PMB 1018
BURLINGTON NC
27215-8315
US

V. Phone/Fax

Practice location:
  • Phone: 919-697-8138
  • Fax:
Mailing address:
  • Phone: 919-697-8138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA22082
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberA22082
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: