Provider Demographics
NPI:1962754564
Name:BENNETT, REBECCA SMART (LPC)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:SMART
Last Name:BENNETT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:S
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:401 SUMMIT ST RM 113
Mailing Address - Street 2:POST OFFICE BOX 206
Mailing Address - City:WINONA
Mailing Address - State:MS
Mailing Address - Zip Code:38967-2240
Mailing Address - Country:US
Mailing Address - Phone:662-283-3379
Mailing Address - Fax:662-283-3375
Practice Address - Street 1:401 SUMMIT ST RM 113
Practice Address - Street 2:POST OFFICE BOX 206
Practice Address - City:WINONA
Practice Address - State:MS
Practice Address - Zip Code:38967-2240
Practice Address - Country:US
Practice Address - Phone:662-283-3379
Practice Address - Fax:662-283-3375
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-05
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1255101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health