Provider Demographics
NPI:1518906718
Name:BENNETT, ROBERT J (LICENSED SCHOOL PSYC)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:J
Last Name:BENNETT
Suffix:
Gender:M
Credentials:LICENSED SCHOOL PSYC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 GREYSTEM CIRCLE
Mailing Address - Street 2:APT 104
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-2197
Mailing Address - Country:US
Mailing Address - Phone:847-704-0009
Mailing Address - Fax:
Practice Address - Street 1:2020 GREYSTEM CIRCLE
Practice Address - Street 2:APT 104
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-2197
Practice Address - Country:US
Practice Address - Phone:847-704-0009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180000475101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional