MEDICARE: MS. REBECCA A. BENNETT LLPC

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	101YP2500X	Professional Counselor	6401010526	MI

General Provider Information

NPI Number	:	1730514910
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. REBECCA A. BENNETT LLPC

Provider Business Mailing Address
First Line	:	72300 ERIKA WAY
Second Line	:	#207
City	:	SOUTH HAVEN
State	:	MI
Zip	:	49090-7120
Country	:	US
Telephone Number	:	616-886-9217
Fax Number	:	269-639-2137

Provider Business Practice Location Address
First Line	:	1675 PHOENIX ROAD
Second Line	:	SUITE 9
City	:	SOUTH HAVEN
State	:	MI
Zip	:	49090
Country	:	US
Telephone Number	:	269-639-2545
Fax Number	:	269-639-2137

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

Provider Enumeration Date	:	09/06/2013
Last Update Date	:	09/06/2013

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