Basic Information
| Provider Information | |||||||||
| NPI: | 1962003830 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENNETT | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | CACI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1170 MARSH LAUREL AVE | ||||||||
| Address2: | |||||||||
| City: | NORTH POLE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997055969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157255918 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3100 S CUSHMAN ST | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997017516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074521648 | ||||||||
| FaxNumber: | 9074564849 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2020 | ||||||||
| LastUpdateDate: | 01/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.