Provider Demographics
NPI:1366893489
Name:BENNETT, MYIA (LPC)
Entity type:Individual
Prefix:
First Name:MYIA
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13155 NOEL RD STE 900
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75240-6882
Mailing Address - Country:US
Mailing Address - Phone:972-435-6453
Mailing Address - Fax:972-947-5273
Practice Address - Street 1:13155 NOEL RD STE 900
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-6882
Practice Address - Country:US
Practice Address - Phone:972-435-6453
Practice Address - Fax:972-947-5273
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-29
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX74888101Y00000X, 101YP2500X, 251S00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No251S00000XAgenciesCommunity/Behavioral Health