Provider Demographics
NPI:1417670001
Name:BENNETT, KOLLEEN MARIE (LMSW)
Entity type:Individual
Prefix:
First Name:KOLLEEN
Middle Name:MARIE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7085 TERRITORIAL RD
Mailing Address - Street 2:
Mailing Address - City:BENTON HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:49022-9458
Mailing Address - Country:US
Mailing Address - Phone:269-313-4002
Mailing Address - Fax:
Practice Address - Street 1:2900 LAKEVIEW AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-2379
Practice Address - Country:US
Practice Address - Phone:269-982-7747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-20
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011144741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical