Provider Demographics
NPI:1447713631
Name:BENNETT, LAURA STEPHANIE
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:STEPHANIE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7108 S KANNER HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-7462
Mailing Address - Country:US
Mailing Address - Phone:708-288-0843
Mailing Address - Fax:
Practice Address - Street 1:16209 FOX CT
Practice Address - Street 2:
Practice Address - City:ORLAND HILLS
Practice Address - State:IL
Practice Address - Zip Code:60487-4635
Practice Address - Country:US
Practice Address - Phone:708-288-0843
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-13
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-18-30286103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst