Provider Demographics
NPI:1275730756
Name:BENNETT, THOMAS OMER (PH D)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:OMER
Last Name:BENNETT
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 MARKLEVILLE LN
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46074-8433
Mailing Address - Country:US
Mailing Address - Phone:317-775-3711
Mailing Address - Fax:
Practice Address - Street 1:50 MARKLEVILLE LN
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:IN
Practice Address - Zip Code:46074-8433
Practice Address - Country:US
Practice Address - Phone:317-775-3711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-28
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040100A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN20040100AOther103TC0700X - PSYCHOLOGIST - CLINICAL