Provider Demographics
NPI:1679513683
Name:BENNETT, THOMAS S (PHD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:S
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 1160
Mailing Address - Street 2:
Mailing Address - City:ORANGE BEACH
Mailing Address - State:AL
Mailing Address - Zip Code:36561-1160
Mailing Address - Country:US
Mailing Address - Phone:251-928-4750
Mailing Address - Fax:
Practice Address - Street 1:3737 GOVERNMENT BLVD STE 203
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36693-4310
Practice Address - Country:US
Practice Address - Phone:251-300-7134
Practice Address - Fax:251-202-7851
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL336103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000071222Medicare PIN
ALR35811Medicare UPIN
AL051528864Medicare ID - Type Unspecified