Healthcare Provider Details

I. General information

NPI: 1629459813
Provider Name (Legal Business Name): MADELEINE BENNET LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2015
Last Update Date: 11/30/2021
Certification Date: 06/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5916 ANAHEIM AVE NE
ALBUQUERQUE NM
87113-1887
US

IV. Provider business mailing address

PO BOX 1363
PENA BLANCA NM
87041-1363
US

V. Phone/Fax

Practice location:
  • Phone: 505-291-6314
  • Fax:
Mailing address:
  • Phone: 505-934-6558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberX-09113
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: