Provider Demographics
NPI:1134302722
Name:BENNETT, KELLY RANDOLPH (PHD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:RANDOLPH
Last Name:BENNETT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9880
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87504-9880
Mailing Address - Country:US
Mailing Address - Phone:505-577-1862
Mailing Address - Fax:505-466-9459
Practice Address - Street 1:578 VIA ARISTA
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87506-4507
Practice Address - Country:US
Practice Address - Phone:505-577-1862
Practice Address - Fax:505-466-9459
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-06
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLPCC 0088061103TC1900X
CAMFC 2017103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling