Provider Demographics
NPI:1053895094
Name:BENNER, MARIE ANNE
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:ANNE
Last Name:BENNER
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 1:1501 WOOD POINTE LN APT 2
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48642-3074
Mailing Address - Country:US
Mailing Address - Phone:989-600-9340
Mailing Address - Fax:
Practice Address - Street 1:301 S CRAPO ST STE 200
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-2941
Practice Address - Country:US
Practice Address - Phone:593-898-9772
Practice Address - Fax:770-198-9775
Is Sole Proprietor?:No
Enumeration Date:2018-09-15
Last Update Date:2018-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011033471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6801103347OtherMICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS