Basic Information
| Provider Information | |||||||||
| NPI: | 1295322626 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENNETT | ||||||||
| FirstName: | IRA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1503 N TIBBS RD | ||||||||
| Address2: | |||||||||
| City: | DALTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307202915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062705033 | ||||||||
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| Practice Location | |||||||||
| Address1: | 419 N WALL ST | ||||||||
| Address2: | |||||||||
| City: | CALHOUN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307011943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066597664 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/31/2020 | ||||||||
| LastUpdateDate: | 12/31/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | CSW006599 | GA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.