Provider Demographics
NPI:1407881352
Name:BENNETT, CAROLYN S (PSYD)
Entity Type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:S
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 1:9 MOUNT RAINIER CT
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-1022
Mailing Address - Country:US
Mailing Address - Phone:415-339-7422
Mailing Address - Fax:
Practice Address - Street 1:1035 SAN PABLO AVE STE 8
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:CA
Practice Address - Zip Code:94706-2277
Practice Address - Country:US
Practice Address - Phone:510-524-8833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 18741103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist