Healthcare Provider Details

I. General information

NPI: 1336698042
Provider Name (Legal Business Name): DEMETRIA BENNETT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2016
Last Update Date: 10/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 PARKWAY STE G
GREENSBORO NC
27401-1653
US

IV. Provider business mailing address

1101 CAROLINA ST
GREENSBORO NC
27401-1318
US

V. Phone/Fax

Practice location:
  • Phone: 336-549-8660
  • Fax:
Mailing address:
  • Phone: 336-333-6860
  • Fax: 336-275-1187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCAS-22910
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: