Provider Demographics
NPI:1891513412
Name:BENNION, CORRYN N
Entity type:Individual
Prefix:
First Name:CORRYN
Middle Name:N
Last Name:BENNION
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 1:225 N 1ST W APT 6
Mailing Address - Street 2:
Mailing Address - City:SAINT ANTHONY
Mailing Address - State:ID
Mailing Address - Zip Code:83445-1451
Mailing Address - Country:US
Mailing Address - Phone:702-490-8845
Mailing Address - Fax:
Practice Address - Street 1:6003 W OVERLAND RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-3073
Practice Address - Country:US
Practice Address - Phone:208-751-0478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-02
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID2161479104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker