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General NPI Number Information
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NPI Number | 1114536018
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Entity Type | Individual
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Provider Name | SAMUEL RICHARD BENNETT
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Gender | Male
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Dates
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Enumeration Date | 07/27/2020
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Last Update Date | 07/27/2020
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Provider Practice Location Address
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Address Line | 5214 N WESTERN AVE
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City | CHICAGO
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State | IL
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Zip | 60625-2589
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Country | US
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Telephone | 773-250-1769
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Fax |
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Provider Business Mailing Address
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Address Line | 1465 LAKE DR
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City | MORRIS
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State | IL
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Zip | 60450-2405
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Country | US
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Telephone | 815-207-3975
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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