Provider Demographics
NPI:1306273784
Name:BENNETT, MARK BARRY (LMSW)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:BARRY
Last Name:BENNETT
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2275 W BROADWAY ST
Mailing Address - Street 2:STE G
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-2902
Mailing Address - Country:US
Mailing Address - Phone:208-524-7400
Mailing Address - Fax:208-524-8004
Practice Address - Street 1:2275 W BROADWAY ST
Practice Address - Street 2:STE G
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-2902
Practice Address - Country:US
Practice Address - Phone:208-524-7400
Practice Address - Fax:208-524-8004
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-01
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-31056104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker