Basic Information
| Provider Information | |||||||||
| NPI: | 1598219495 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENNETT | ||||||||
| FirstName: | CARRIE | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LOGAN | ||||||||
| OtherFirstName: | CARRIE | ||||||||
| OtherMiddleName: | E | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 547 E 11TH AVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432112603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142244506 | ||||||||
| FaxNumber: | 6142910118 | ||||||||
| Practice Location | |||||||||
| Address1: | 547 E 11TH AVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432112603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142244506 | ||||||||
| FaxNumber: | 6142910118 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2016 | ||||||||
| LastUpdateDate: | 04/18/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | RN414025 | OH | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health | 363LP0808X | APRN.CNP.019788 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 0185403 | 05 | OH | MEDICAID |