Provider Demographics
NPI:1598069676
Name:BENN, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BENN
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:CAMPUS DELIVERY 8010
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80523-8010
Mailing Address - Country:US
Mailing Address - Phone:970-491-5728
Mailing Address - Fax:
Practice Address - Street 1:CAMPUS DELIVERY 8010
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80523-8010
Practice Address - Country:US
Practice Address - Phone:970-491-5728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-04
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1597103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling