Provider Demographics
NPI:1699245357
Name:BENNETT, TREVON (BSW, MSW)
Entity type:Individual
Prefix:
First Name:TREVON
Middle Name:
Last Name:BENNETT
Suffix:
Gender:M
Credentials:BSW, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 FAIRWAY PARK DR APT 201
Mailing Address - Street 2:
Mailing Address - City:COPLEY
Mailing Address - State:OH
Mailing Address - Zip Code:44321-2997
Mailing Address - Country:US
Mailing Address - Phone:330-414-6302
Mailing Address - Fax:
Practice Address - Street 1:3801 FAIRWAY PARK DR APT 201
Practice Address - Street 2:
Practice Address - City:COPLEY
Practice Address - State:OH
Practice Address - Zip Code:44321-2997
Practice Address - Country:US
Practice Address - Phone:330-414-6302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-26
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1904067106H00000X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist