Organization
ILLUMII
Active
Organization
ILLUMII
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. KRISTIN R BENNETT PHD. (DIRECTOR)
(336) 893-9018
Entity
Organization
Contact information
Practice address
121 REYNOLDA VLG STE A, WINSTON SALEM, NC 27106-5126
(336) 893-9018
(833) 748-0121
Mailing address
121 REYNOLDA VLG STE A, WINSTON SALEM, NC 27106-5126
(336) 893-9018
(833) 748-0121
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
—
—
103TC0700X
Clinical Psychologist
—
—
207Q00000X
Family Medicine Physician
—
—
261Q00000X
Clinic/Center
Primary
—
—
Other
Enumeration date
06/12/2020
Last updated
06/12/2020
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