Basic Information
| Provider Information | |||||||||
| NPI: | 1609228220 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENNETT | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | CHANDLER A. | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 515 E BROAD ST | ||||||||
| Address2: | |||||||||
| City: | STATESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286775330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2523779063 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4612 NASH ST N | ||||||||
| Address2: | |||||||||
| City: | WILSON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278968725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2522815044 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2016 | ||||||||
| LastUpdateDate: | 03/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C011607 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.