Provider Demographics
NPI:1962461780
Name:BENNETT, THOMAS L (PHD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:L
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 1:213 CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-8907
Mailing Address - Country:US
Mailing Address - Phone:970-493-6667
Mailing Address - Fax:970-493-8016
Practice Address - Street 1:1045 ROBERTSON ST
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-3926
Practice Address - Country:US
Practice Address - Phone:970-493-6667
Practice Address - Fax:970-493-8016
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO895103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist