1710150644 NPI number — MICHAEL H. BENNETT, PH.D.

Table of content: (NPI 1710150644)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710150644 NPI number — MICHAEL H. BENNETT, PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHAEL H. BENNETT, PH.D.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710150644
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/13/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3608 PRESTON RD
Provider Second Line Business Mailing Address:
STE. 150
Provider Business Mailing Address City Name:
PLANO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75093-8655
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
469-467-0644
Provider Business Mailing Address Fax Number:
972-509-1450

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3608 PRESTON RD
Provider Second Line Business Practice Location Address:
STE. 150
Provider Business Practice Location Address City Name:
PLANO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75093-8655
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
469-467-0644
Provider Business Practice Location Address Fax Number:
972-509-1450
Provider Enumeration Date:
04/11/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BENNETT
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
HARRIS
Authorized Official Title or Position:
CLINICAL PSYCHOLOGIST
Authorized Official Telephone Number:
469-467-0644

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  2-5024 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TF0200X , with the licence number: 2-5024 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 122065901 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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