Provider Demographics
NPI:1508478801
Name:BENNETT, CALEB R
Entity Type:Individual
Prefix:
First Name:CALEB
Middle Name:R
Last Name:BENNETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 COTTONTAIL LN
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:NJ
Mailing Address - Zip Code:08873-5125
Mailing Address - Country:US
Mailing Address - Phone:732-529-7120
Mailing Address - Fax:
Practice Address - Street 1:115 N 8TH ST
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-3307
Practice Address - Country:US
Practice Address - Phone:719-275-3968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAUD.0001021231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist