Provider Demographics
NPI:1184282212
Name:BENNETT, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BENNETT
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6416 NW 5TH WAY
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-6112
Mailing Address - Country:US
Mailing Address - Phone:888-754-0398
Mailing Address - Fax:954-982-6491
Practice Address - Street 1:1347 N ALMA SCHOOL RD STE 220
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-5932
Practice Address - Country:US
Practice Address - Phone:888-754-0398
Practice Address - Fax:954-982-6491
Is Sole Proprietor?:No
Enumeration Date:2019-06-04
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106E00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36-123419Medicaid