Provider Demographics
NPI:1467464081
Name:BENNETT, ELISABETH D (PHD)
Entity Type:Individual
Prefix:
First Name:ELISABETH
Middle Name:D
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 280
Mailing Address - Street 2:
Mailing Address - City:COLBERT
Mailing Address - State:WA
Mailing Address - Zip Code:99005-0280
Mailing Address - Country:US
Mailing Address - Phone:509-323-3512
Mailing Address - Fax:509-323-5964
Practice Address - Street 1:502 E BOONE AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99258-1774
Practice Address - Country:US
Practice Address - Phone:509-981-8509
Practice Address - Fax:509-323-5964
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00002225103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical