Provider Demographics
NPI:1083155709
Name:WHEAT, BENNIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:BENNIE
Middle Name:
Last Name:WHEAT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:BEN
Other - Middle Name:
Other - Last Name:WHEAT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:3717 NATIONAL DR STE 208
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-4877
Mailing Address - Country:US
Mailing Address - Phone:817-807-3457
Mailing Address - Fax:
Practice Address - Street 1:3717 NATIONAL DR STE 208
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-4877
Practice Address - Country:US
Practice Address - Phone:817-807-3457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-14
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5136103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical