Provider Demographics
NPI:1023660891
Name:BENNETT, LORRAINE (TLLP, LPC)
Entity type:Individual
Prefix:
First Name:LORRAINE
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:TLLP, LPC
Other - Prefix:
Other - First Name:DUSTY
Other - Middle Name:LORRAINE
Other - Last Name:PITTMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6054 IN THE PINES DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49548-8503
Mailing Address - Country:US
Mailing Address - Phone:616-432-0787
Mailing Address - Fax:
Practice Address - Street 1:2180 44TH ST SE STE 301
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-5093
Practice Address - Country:US
Practice Address - Phone:616-259-5112
Practice Address - Fax:616-971-6157
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-11
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401020248101YP2500X
MI6362006230103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling