Provider Demographics
NPI:1093007304
Name:BENNETT, LORI BETH (MD/PHD)
Entity Type:Individual
Prefix:DR
First Name:LORI
Middle Name:BETH
Last Name:BENNETT
Suffix:
Gender:F
Credentials:MD/PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-8752
Mailing Address - Fax:
Practice Address - Street 1:301 DEINHARD LN
Practice Address - Street 2:
Practice Address - City:MCCALL
Practice Address - State:ID
Practice Address - Zip Code:83638-4703
Practice Address - Country:US
Practice Address - Phone:208-630-2450
Practice Address - Fax:208-634-4055
Is Sole Proprietor?:No
Enumeration Date:2011-05-04
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2663632084P0800X, 2084P0802X
IDM-146942084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry