Provider Demographics
NPI:1750323705
Name:BENNETT, BERT III (PHD)
Entity Type:Individual
Prefix:DR
First Name:BERT
Middle Name:
Last Name:BENNETT
Suffix:III
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 1:1684 CHICKASHA DR
Mailing Address - Street 2:
Mailing Address - City:PFAFFTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:27040-8210
Mailing Address - Country:US
Mailing Address - Phone:336-638-1812
Mailing Address - Fax:336-946-1075
Practice Address - Street 1:3111 MAPLEWOOD AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3906
Practice Address - Country:US
Practice Address - Phone:336-624-6412
Practice Address - Fax:336-724-3839
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1361103TC1900X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6000742Medicaid
NC6000742Medicaid