MEDICARE: EVAN 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	101YM0800X	Mental Health Counselor

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1972938280
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EVAN BENNETT

Provider Business Mailing Address
First Line	:	PO BOX 48
Second Line	:
City	:	MEAD
State	:	OK
Zip	:	73449-0048
Country	:	US
Telephone Number	:	580-745-9610
Fax Number	:	580-745-9891

Provider Business Practice Location Address
First Line	:	2601 NORTH WEST EXPRESSWAY
Second Line	:	SUITE 101E
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-7272
Country	:	US
Telephone Number	:	405-858-8656
Fax Number	:	580-745-9891

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

Provider Enumeration Date	:	09/05/2013
Last Update Date	:	09/05/2013

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Directions to “ EVAN BENNETT ” Practice Location

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