1700366085 NPI number — TERESEA L BENNETT LMSW, LCAC

Table of content: TIFFENY BURKE MA-P #PC61296748 (NPI 1992528137)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700366085 NPI number — TERESEA L BENNETT LMSW, LCAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BENNETT
Provider First Name:
TERESEA
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMSW, LCAC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BENNETT
Provider Other First Name:
TESS
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMSW, LCAC
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1700366085
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1917 MONROE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELLIS
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67637-1905
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
785-623-3482
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2501 E 13TH
Provider Second Line Business Practice Location Address:
BUILDING 3 SUITE 10
Provider Business Practice Location Address City Name:
HAYS
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-628-3573
Provider Business Practice Location Address Fax Number:
785-621-2257
Provider Enumeration Date:
08/16/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  103 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 104100000X , with the licence number: 10020 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)