Healthcare Provider Details

I. General information

NPI: 1356255426
Provider Name (Legal Business Name): GLORIA RENEE BENNETT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 WEATHERSTONE DR APT 201
FAYETTEVILLE NC
28311-7008
US

IV. Provider business mailing address

109 WEATHERSTONE DR APT 201
FAYETTEVILLE NC
28311-7008
US

V. Phone/Fax

Practice location:
  • Phone: 472-272-0817
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: