Healthcare Provider Details

I. General information

NPI: 1750450912
Provider Name (Legal Business Name): MARY E S BENNETT LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 MECHANIC ST RECOVERY CENTER SUITE 360
LEBANON NH
03766
US

IV. Provider business mailing address

9 HANOVER ST WEST CENTRAL SERVICES INC SUITE 2
LEBANON NH
03766
US

V. Phone/Fax

Practice location:
  • Phone: 603-448-5610
  • Fax: 603-448-8260
Mailing address:
  • Phone: 603-448-0126
  • Fax: 603-448-6001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSW011138L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number046849
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number871
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: