Provider Demographics
NPI:1699252502
Name:BENNETT, MIRANDA (BCBA)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 ELFORD CT
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29306-3250
Mailing Address - Country:US
Mailing Address - Phone:864-804-4895
Mailing Address - Fax:
Practice Address - Street 1:200 ELFORD CT
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29306-3250
Practice Address - Country:US
Practice Address - Phone:864-804-4895
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-24
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1-20-41378103K00000X
SC17-35816106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician