Provider Demographics
NPI:1154664076
Name:BENNETT, SHOSHANA (PHD)
Entity Type:Individual
Prefix:
First Name:SHOSHANA
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
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 128
Mailing Address - Street 2:
Mailing Address - City:BODEGA BAY
Mailing Address - State:CA
Mailing Address - Zip Code:94923-0128
Mailing Address - Country:US
Mailing Address - Phone:707-875-9961
Mailing Address - Fax:
Practice Address - Street 1:21413 HERON DR
Practice Address - Street 2:
Practice Address - City:BODEGA BAY
Practice Address - State:CA
Practice Address - Zip Code:94923-0128
Practice Address - Country:US
Practice Address - Phone:707-875-9961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-28
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19433103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist