Healthcare Provider Details

I. General information

NPI: 1184344533
Provider Name (Legal Business Name): SAMANTHA BENNETT LCSW THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2022
Last Update Date: 10/03/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

918 NE 5TH ST
BEND OR
97701-4617
US

IV. Provider business mailing address

70 SW CENTURY DR STE 100
BEND OR
97702-3558
US

V. Phone/Fax

Practice location:
  • Phone: 541-771-8170
  • Fax:
Mailing address:
  • Phone: 541-771-8170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: SAMANTHA L BENNETT
Title or Position: OWNER
Credential: LCSW
Phone: 541-771-8170