MEDICARE: MS. ASHLEY BENNETT

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	390200000X	Student in an Organized Health Care Education/Training Program
2	104100000X	Social Worker

General Provider Information

NPI Number	:	1740811538
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ASHLEY BENNETT

Provider Business Mailing Address
First Line	:	590 NW PEACOCK BLVD
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34986-2213
Country	:	US
Telephone Number	:	772-410-5902
Fax Number	:

Provider Business Practice Location Address
First Line	:	590 NW PEACOCK BLVD STE 1
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34986-2213
Country	:	US
Telephone Number	:	772-348-0900
Fax Number	:

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

Provider Enumeration Date	:	01/30/2020
Last Update Date	:	03/07/2022

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