1114075512 NPI number — MRS. ELLEN BENNETT PHD.

Table of content: MRS. ELLEN BENNETT PHD. (NPI 1114075512)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114075512 NPI number — MRS. ELLEN BENNETT PHD.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BENNETT
Provider First Name:
ELLEN
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PHD.
Provider Gender Code:
F

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:
1114075512
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/26/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
109 S FESTIVAL DR
Provider Second Line Business Mailing Address:
EL PASO
Provider Business Mailing Address City Name:
EL PASO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79912-5801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
915-845-8787
Provider Business Mailing Address Fax Number:
915-821-5370

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
109 S FESTIVAL DR
Provider Second Line Business Practice Location Address:
EL PASO
Provider Business Practice Location Address City Name:
EL PASO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79912-5801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
915-845-8787
Provider Business Practice Location Address Fax Number:
915-821-5370
Provider Enumeration Date:
01/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 528347 . This is a "BCBS PROVIDER NO." identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 742832177 . This is a "TAX IDENTIFICATION NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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