Provider Demographics
NPI:1104141175
Name:BENNETT, HEIDI SUE (LADC)
Entity type:Individual
Prefix:MS
First Name:HEIDI
Middle Name:SUE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORWAY
Mailing Address - State:ME
Mailing Address - Zip Code:04268-5943
Mailing Address - Country:US
Mailing Address - Phone:207-739-2644
Mailing Address - Fax:207-739-2467
Practice Address - Street 1:89 MAIN ST
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:ME
Practice Address - Zip Code:04257-1440
Practice Address - Country:US
Practice Address - Phone:207-739-2644
Practice Address - Fax:207-739-2467
Is Sole Proprietor?:No
Enumeration Date:2010-04-02
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECAC3731101YA0400X
MELC5006101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)