=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245052406
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHAQUOYA BENNETT LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2024
-----------------------------------------------------
Last Update Date | 10/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1314 CONEY ISLAND AVE APT 2F
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-361-2079
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1314 CONEY ISLAND AVE APT 2F
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-361-2079
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 124751
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------