Individual
TONYA BENNETT
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
2702 ETHEL AVE, INDIANAPOLIS, IN 46208-5160
(317) 772-2673
Mailing address
2702 ETHEL AVE, INDIANAPOLIS, IN 46208-5160
(317) 772-2673
Taxonomy
Speciality
Code
Description
License number
State
171M00000X
Case Manager/Care Coordinator
Primary
—
—
310500000X
Mental Illness Intermediate Care Facility
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
123456
RECOVERY WORKS
—
Enumeration date
01/20/2019
Last updated
01/24/2019
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