Provider Demographics
NPI:1770194029
Name:BENNETT, STEPHEN DOUGLAS (MA, NCC, LBS)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:DOUGLAS
Last Name:BENNETT
Suffix:
Gender:M
Credentials:MA, NCC, LBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 BIRMINGHAM WAY
Mailing Address - Street 2:
Mailing Address - City:EXTON
Mailing Address - State:PA
Mailing Address - Zip Code:19341-2745
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:390 WATERLOO BLVD
Practice Address - Street 2:
Practice Address - City:EXTON
Practice Address - State:PA
Practice Address - Zip Code:19341-2624
Practice Address - Country:US
Practice Address - Phone:610-363-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-11
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH004783251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health