Provider Demographics
NPI:1629104765
Name:BENNETT, RODERICK MACLEAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:RODERICK
Middle Name:MACLEAN
Last Name:BENNETT
Suffix:
Gender:M
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 7
Mailing Address - Street 2:
Mailing Address - City:BASKING RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07920-0007
Mailing Address - Country:US
Mailing Address - Phone:908-766-1221
Mailing Address - Fax:908-766-9577
Practice Address - Street 1:61 CLAREMONT RD
Practice Address - Street 2:
Practice Address - City:BERNARDSVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07924-2200
Practice Address - Country:US
Practice Address - Phone:908-766-1221
Practice Address - Fax:908-766-9577
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00170200103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ694505Medicare ID - Type Unspecified