MEDICARE: MRS. STACIE CAMP BENNETT MA, LPC

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	3813	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1902955503
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. STACIE CAMP BENNETT MA, LPC

Provider Business Mailing Address
First Line	:	449 PAUL H. BEAM ROAD
Second Line	:
City	:	CHERRYVILLE
State	:	NC
Zip	:	28021
Country	:	US
Telephone Number	:	704-301-8093
Fax Number	:	704-301-8093

Provider Business Practice Location Address
First Line	:	809 N LAFAYETTE ST
Second Line	:	SUITE A
City	:	SHELBY
State	:	NC
Zip	:	28150-3978
Country	:	US
Telephone Number	:	704-301-8093
Fax Number	:	704-301-8093

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

Provider Enumeration Date	:	01/10/2007
Last Update Date	:	06/18/2015

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