Provider Demographics
NPI:1508325903
Name:BENNETT, NICHOLAS KEITH (PSYD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:KEITH
Last Name:BENNETT
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:DR
Other - First Name:NICHOLAS
Other - Middle Name:BENNETT
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:2035 N PUMP HOUSE LN
Mailing Address - Street 2:
Mailing Address - City:SANTA PAULA
Mailing Address - State:CA
Mailing Address - Zip Code:93060-8022
Mailing Address - Country:US
Mailing Address - Phone:805-203-6673
Mailing Address - Fax:805-800-8929
Practice Address - Street 1:2035 N PUMP HOUSE LN
Practice Address - Street 2:
Practice Address - City:SANTA PAULA
Practice Address - State:CA
Practice Address - Zip Code:93060-8022
Practice Address - Country:US
Practice Address - Phone:805-203-6673
Practice Address - Fax:805-800-8929
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-15
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY33288103T00000X, 103TP2701X, 103TC0700X, 103TC1900X
WV1336103T00000X
WV103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling