Individual
MR. MARK BARRY BENNETT
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
LMSW
Contact information
Practice address
2275 W BROADWAY ST, STE G, IDAHO FALLS, ID 83402-2902
(208) 524-7400
(208) 524-8004
Mailing address
2275 W BROADWAY ST, STE G, IDAHO FALLS, ID 83402-2902
(208) 524-7400
(208) 524-8004
Taxonomy
Speciality
Code
Description
License number
State
104100000X
Social Worker
Primary
LMSW-31056
ID
Other
Enumeration date
10/01/2013
Last updated
10/01/2013
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