Provider Demographics
NPI:1043789886
Name:BENNETT, ANDREW MICHAEL (CCC-SLP)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:MICHAEL
Last Name:BENNETT
Suffix:
Gender:M
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5931 E UNIVERSITY BLVD APT 126
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-9109
Mailing Address - Country:US
Mailing Address - Phone:214-793-7152
Mailing Address - Fax:
Practice Address - Street 1:2621 W AIRPORT FWY
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75062-6020
Practice Address - Country:US
Practice Address - Phone:972-600-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-23
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
14305307235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist