1194911883 NPI number — WILLIAM S BENNETT PHD PC

Table of content: (NPI 1194911883)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194911883 NPI number — WILLIAM S BENNETT PHD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILLIAM S BENNETT PHD PC
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:
1194911883
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2311 CANTERWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILMINGTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-343-1474
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2311 CANTERWOOD DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-343-1474
Provider Business Practice Location Address Fax Number:
910-763-1482
Provider Enumeration Date:
09/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BENNETT
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
SCOTT
Authorized Official Title or Position:
CLINICAL PSYCHOLOGIST
Authorized Official Telephone Number:
910-343-1474

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  2177 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6000525 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0328U . This is a "BLUE CROSS BLUE SHIELD NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 61-100549 . This is a "UNITED BEHAVIORAL HEALTH" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1051812 . This is a "CIGNA/MCC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 75117 . This is a "MEDCOST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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