Provider Demographics
NPI:1427401488
Name:BENNINGTON, MANDI
Entity type:Individual
Prefix:
First Name:MANDI
Middle Name:
Last Name:BENNINGTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1197 S BUCHANAN ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60481-1616
Mailing Address - Country:US
Mailing Address - Phone:815-603-4561
Mailing Address - Fax:
Practice Address - Street 1:1197 S BUCHANAN ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:IL
Practice Address - Zip Code:60481-1616
Practice Address - Country:US
Practice Address - Phone:815-603-4561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-14
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst