MEDICARE: BRISEIDA N/A BENNETT LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	20048	OK
2	1041C0700X	Clinical Social Worker	22045	OK

General Provider Information

NPI Number	:	1316638216
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRISEIDA N/A BENNETT LCSW

Provider Business Mailing Address
First Line	:	1100 NE 13TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73117-1039
Country	:	US
Telephone Number	:	405-271-5700
Fax Number	:

Provider Business Practice Location Address
First Line	:	1100 NE 13TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73117-1039
Country	:	US
Telephone Number	:	405-271-5700
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/19/2023
Last Update Date	:	05/28/2026

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