Provider Demographics
NPI:1679603393
Name:BENNETT, KATHERINE VICK (LMSW)
Entity type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:VICK
Last Name:BENNETT
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:MRS
Other - First Name:KATHERINE
Other - Middle Name:ANN
Other - Last Name:VICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:410 E SHOCKLEY FERRY ROAD
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29624-3847
Mailing Address - Country:US
Mailing Address - Phone:864-225-6266
Mailing Address - Fax:864-225-6267
Practice Address - Street 1:410 E SHOCKLEY FERRY ROAD
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29624-3847
Practice Address - Country:US
Practice Address - Phone:864-225-6266
Practice Address - Fax:864-225-6267
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC007387104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP1385Medicaid
SCGP1385Medicaid