Provider Demographics
NPI:1790777399
Name:BENNETT, ROBERT WINSTON JR (PHD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:WINSTON
Last Name:BENNETT
Suffix:JR
Gender:M
Credentials:PHD
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Mailing Address - Street 1:1380 LEAD HILL BLVD
Mailing Address - Street 2:STE. 110
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-2941
Mailing Address - Country:US
Mailing Address - Phone:916-556-4178
Mailing Address - Fax:916-786-3080
Practice Address - Street 1:1380 LEAD HILL BLVD
Practice Address - Street 2:STE. 110
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-2941
Practice Address - Country:US
Practice Address - Phone:916-556-4178
Practice Address - Fax:916-786-3080
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPSY17517103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP60976Medicare UPIN
CA0PL175170Medicare ID - Type Unspecified