Provider Demographics
NPI:1457144792
Name:BENNIS, SUSAN MARIE (PPS-200171407)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:BENNIS
Suffix:
Gender:F
Credentials:PPS-200171407
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12555 NAVAJO RD
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92308-7256
Mailing Address - Country:US
Mailing Address - Phone:760-247-8001
Mailing Address - Fax:
Practice Address - Street 1:22900 ESAWS RD
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-4305
Practice Address - Country:US
Practice Address - Phone:760-961-2290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-28
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool