Provider Demographics
NPI:1063956324
Name:BENNETT, ERITH (LAPC)
Entity type:Individual
Prefix:MR
First Name:ERITH
Middle Name:
Last Name:BENNETT
Suffix:
Gender:M
Credentials:LAPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 WHITE TAIL CT
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-4918
Mailing Address - Country:US
Mailing Address - Phone:240-938-0175
Mailing Address - Fax:
Practice Address - Street 1:530 PARKWOOD WAY
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-1309
Practice Address - Country:US
Practice Address - Phone:770-460-0970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-06
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC004852101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health