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General NPI Number Information
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NPI Number | 1285396481
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Entity Type | Organization
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Legal Business Name | MARK BENNETT PLLC
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Dates
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Enumeration Date | 10/06/2021
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Last Update Date | 10/06/2021
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Provider Practice Location Address
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Address Line | 2775 CHANNING WAY
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City | IDAHO FALLS
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State | ID
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Zip | 83404-7510
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Country | US
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Telephone | 208-524-0133
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Fax |
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Provider Business Mailing Address
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Address Line | 320 RED FOX DR
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City | IDAHO FALLS
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State | ID
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Zip | 83401-3479
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Country | US
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Telephone | 208-521-9437
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Fax |
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Authorized Official
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Title or Position | CLINICAL SOCIAL WORKER
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Name | MR. MARK BARRY BENNETT
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Credential | LCSW
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Telephone | 208-521-9437
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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