Provider Demographics
NPI:1134285224
Name:BENNETT, MARC (PSYD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:
Last Name:BENNETT
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16550 VENTURA BLVD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2004
Mailing Address - Country:US
Mailing Address - Phone:818-309-9938
Mailing Address - Fax:
Practice Address - Street 1:16550 VENTURA BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2004
Practice Address - Country:US
Practice Address - Phone:818-309-9938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-31
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 19505103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical