Provider Demographics
NPI:1326397860
Name:BENNETT, KORI (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KORI
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 WEST END AVENUE
Mailing Address - Street 2:1D
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025
Mailing Address - Country:US
Mailing Address - Phone:909-969-8291
Mailing Address - Fax:
Practice Address - Street 1:825 WEST END AVENUE
Practice Address - Street 2:1D
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025
Practice Address - Country:US
Practice Address - Phone:909-969-8291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-30
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021516103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical